Provider Demographics
NPI:1801649256
Name:SPARK SPEECH THERAPY LLC
Entity type:Organization
Organization Name:SPARK SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIMMO
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:810-429-9545
Mailing Address - Street 1:206 N HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2195
Mailing Address - Country:US
Mailing Address - Phone:810-429-9545
Mailing Address - Fax:
Practice Address - Street 1:206 N HOWARD ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2195
Practice Address - Country:US
Practice Address - Phone:810-429-9545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty