Provider Demographics
NPI:1477103398
Name:GREAT BASIN SPEECH THERAPY LLC
Entity type:Organization
Organization Name:GREAT BASIN SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:
Authorized Official - First Name:AZRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:530-448-2135
Mailing Address - Street 1:100 SILVERSTONE PL
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-1326
Mailing Address - Country:US
Mailing Address - Phone:775-453-0217
Mailing Address - Fax:775-800-5956
Practice Address - Street 1:100 SILVERSTONE PL
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1326
Practice Address - Country:US
Practice Address - Phone:775-453-0217
Practice Address - Fax:775-800-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-12
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1386051175Medicaid