Provider Demographics
NPI:1831516285
Name:TLC SPEECH THERAPY, INC
Entity type:Organization
Organization Name:TLC SPEECH THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSI
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:WAGNER BERMANK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:303-883-2293
Mailing Address - Street 1:626 GOLDEN EAGLE CIR
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-0909
Mailing Address - Country:US
Mailing Address - Phone:303-883-2293
Mailing Address - Fax:866-543-7981
Practice Address - Street 1:626 GOLDEN EAGLE CIR
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-0909
Practice Address - Country:US
Practice Address - Phone:303-883-2293
Practice Address - Fax:866-543-7981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000037251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03051781Medicaid
CO12040893OtherAMERICAN SPEECH AND HEARING ASSOCIATION
CO0000037OtherCOLORADO LICENSE #