Provider Demographics
NPI:1881894202
Name:MICHAEL ALLEN DOUGLAS & KIMBERLI C DOUGLAS BOUNCE BACK SPEECH THERAPY
Entity type:Organization
Organization Name:MICHAEL ALLEN DOUGLAS & KIMBERLI C DOUGLAS BOUNCE BACK SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:480-274-3951
Mailing Address - Street 1:1950 E LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-0821
Mailing Address - Country:US
Mailing Address - Phone:480-274-3951
Mailing Address - Fax:480-718-7987
Practice Address - Street 1:1950 E LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-0821
Practice Address - Country:US
Practice Address - Phone:480-274-3951
Practice Address - Fax:480-718-7987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5027251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health