Provider Demographics
NPI:1669995700
Name:MIDNIGHT SUN SPEECH CLINIC, LLC
Entity type:Organization
Organization Name:MIDNIGHT SUN SPEECH CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:907-622-2122
Mailing Address - Street 1:10928 EAGLE RIVER RD STE 104
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8079
Mailing Address - Country:US
Mailing Address - Phone:907-622-2122
Mailing Address - Fax:855-368-5399
Practice Address - Street 1:10928 EAGLE RIVER RD STE 104
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8079
Practice Address - Country:US
Practice Address - Phone:907-622-2122
Practice Address - Fax:855-368-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKSLPS518235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty