Provider Demographics
NPI:1952879710
Name:BLYTHE, LARRY KEITH (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:KEITH
Last Name:BLYTHE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16351 SUMMERLIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-5764
Mailing Address - Country:US
Mailing Address - Phone:239-454-6130
Mailing Address - Fax:
Practice Address - Street 1:16351 SUMMERLIN RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5764
Practice Address - Country:US
Practice Address - Phone:239-454-6130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist