Provider Demographics
NPI:1770248056
Name:MARIPOSA SPEECH THERAPY LLC
Entity type:Organization
Organization Name:MARIPOSA SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIDSTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:208-757-3250
Mailing Address - Street 1:60 YACHT CLUB DR NE APT 10
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-8800
Mailing Address - Country:US
Mailing Address - Phone:208-757-3250
Mailing Address - Fax:
Practice Address - Street 1:60 YACHT CLUB DR NE APT 10
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-8800
Practice Address - Country:US
Practice Address - Phone:208-757-3250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty