Provider Demographics
NPI:1831764919
Name:ICEBERG THERAPY SERVICES LLC
Entity type:Organization
Organization Name:ICEBERG THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGAUGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC-SLP
Authorized Official - Phone:225-277-3442
Mailing Address - Street 1:7350 JEFFERSON HWY
Mailing Address - Street 2:SUITE 485 #231
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806
Mailing Address - Country:US
Mailing Address - Phone:225-277-3442
Mailing Address - Fax:
Practice Address - Street 1:172 LEE DR STE 485
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-5088
Practice Address - Country:US
Practice Address - Phone:225-277-3442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty