Provider Demographics
NPI:1831339928
Name:ISLAND SPEECH LANGUAGE & REHABILITATION, INC.
Entity type:Organization
Organization Name:ISLAND SPEECH LANGUAGE & REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:360-679-4211
Mailing Address - Street 1:390 NE MIDWAY BLVD
Mailing Address - Street 2:SUITE B-101
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-2642
Mailing Address - Country:US
Mailing Address - Phone:360-679-4211
Mailing Address - Fax:360-279-2545
Practice Address - Street 1:390 NE MIDWAY BLVD
Practice Address - Street 2:SUITE B-101
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-2642
Practice Address - Country:US
Practice Address - Phone:360-679-4211
Practice Address - Fax:360-279-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL0003493235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty