Provider Demographics
NPI:1770988669
Name:PEDIATRIC SPEECH LANGUAGE THERAPY, PLLC
Entity type:Organization
Organization Name:PEDIATRIC SPEECH LANGUAGE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:SOLDAN
Authorized Official - Last Name:BROADFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:252-339-8145
Mailing Address - Street 1:1216 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-6652
Mailing Address - Country:US
Mailing Address - Phone:252-339-8145
Mailing Address - Fax:252-338-9156
Practice Address - Street 1:1216 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6652
Practice Address - Country:US
Practice Address - Phone:252-339-8145
Practice Address - Fax:252-338-9156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11106251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services