Provider Demographics
NPI:1629880489
Name:BOBART, BERYL ALEXANDRA (SLP-CCC)
Entity type:Individual
Prefix:
First Name:BERYL
Middle Name:ALEXANDRA
Last Name:BOBART
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 AUTUMN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2542
Mailing Address - Country:US
Mailing Address - Phone:843-446-8587
Mailing Address - Fax:
Practice Address - Street 1:701 LIBERTY RIDGE LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4564
Practice Address - Country:US
Practice Address - Phone:843-446-8587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY292464235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist