Provider Demographics
NPI:1932732112
Name:ADVANCED SPEECH THERAPY LLC
Entity Type:Organization
Organization Name:ADVANCED SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEZIME
Authorized Official - Middle Name:
Authorized Official - Last Name:DJONOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:201-675-3396
Mailing Address - Street 1:59 BEAVERBROOK RD STE 303C
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1772
Mailing Address - Country:US
Mailing Address - Phone:201-675-3396
Mailing Address - Fax:
Practice Address - Street 1:59 BEAVERBROOK RD STE 303C
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1772
Practice Address - Country:US
Practice Address - Phone:201-675-3396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1497211403OtherNPI
NJ1235543547OtherNPI