Provider Demographics
NPI:1649933250
Name:SPEAKEASY CLINIC
Entity type:Organization
Organization Name:SPEAKEASY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LATADY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:228-219-4793
Mailing Address - Street 1:1403 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-1626
Mailing Address - Country:US
Mailing Address - Phone:228-219-4793
Mailing Address - Fax:
Practice Address - Street 1:3452 PASCAGOULA ST STE 2
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-3203
Practice Address - Country:US
Practice Address - Phone:228-219-4793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty