Provider Demographics
NPI:1801129994
Name:SPEECH PATHOLOGY ENRICHMENT LANGUAGE & LITERACY CLINIC
Entity type:Organization
Organization Name:SPEECH PATHOLOGY ENRICHMENT LANGUAGE & LITERACY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:GRAVLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:907-336-7323
Mailing Address - Street 1:4050 LAKE OTIS PKWY
Mailing Address - Street 2:SUITE 204-C
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5223
Mailing Address - Country:US
Mailing Address - Phone:907-336-7323
Mailing Address - Fax:907-277-7355
Practice Address - Street 1:4050 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 204-C
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5223
Practice Address - Country:US
Practice Address - Phone:907-336-7323
Practice Address - Fax:907-277-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK239235Z00000X
AK90235Z00000X
AK285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP0003Medicaid
AKSP5061Medicaid
AKSP6595Medicaid