Provider Demographics
NPI:1720524598
Name:PEDIATRIC SPEECH LAB
Entity Type:Organization
Organization Name:PEDIATRIC SPEECH LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:QUINTINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:301-885-0033
Mailing Address - Street 1:11350 PEMBROOKE SQ STE 313
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4809
Mailing Address - Country:US
Mailing Address - Phone:301-885-0033
Mailing Address - Fax:
Practice Address - Street 1:11350 PEMBROOKE SQ STE 313
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4809
Practice Address - Country:US
Practice Address - Phone:301-885-0033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X, 251S00000X, 261QM1300X
DCSLP000879235Z00000X
MD08341235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty