Provider Demographics
NPI:1336591163
Name:SHERIDAN SPEECH THERAPY
Entity Type:Organization
Organization Name:SHERIDAN SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:SHERIDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC S
Authorized Official - Phone:740-479-2395
Mailing Address - Street 1:3040 PREAKNESS CT
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1093
Mailing Address - Country:US
Mailing Address - Phone:740-479-2395
Mailing Address - Fax:
Practice Address - Street 1:3040 PREAKNESS CT
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:KY
Practice Address - Zip Code:41169-1093
Practice Address - Country:US
Practice Address - Phone:740-479-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY141919252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========Medicaid