Provider Demographics
NPI:1750896932
Name:RAINIER SPEECH THERAPY LLC
Entity type:Organization
Organization Name:RAINIER SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROCKMAN-HAWE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:530-318-8306
Mailing Address - Street 1:PO BOX 12022
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-2022
Mailing Address - Country:US
Mailing Address - Phone:530-318-8306
Mailing Address - Fax:
Practice Address - Street 1:2108 CATON WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1105
Practice Address - Country:US
Practice Address - Phone:530-318-8306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-09
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60514608235Z00000X
MD14051323235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty