MEDICARE: EXECUTIVE SPEECH INNOVATIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1477392074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE SPEECH INNOVATIONS, LLC

Provider Business Mailing Address
First Line	:	1802 TYNDALL POINT RD
Second Line	:
City	:	GLOUCESTER POINT
State	:	VA
Zip	:	23062-2316
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1802 TYNDALL POINT RD
Second Line	:
City	:	GLOUCESTER POINT
State	:	VA
Zip	:	23062-2316
Country	:	US
Telephone Number	:	804-286-0080
Fax Number	:

Authorized Official
Title or Position	:	OWNER, SPEECH-LANGUAGE PATHOLOGIST
Name	:	ALLISON WALKER
Credential	:	MS, CCC-SLP
Telephone Number	:	804-286-0080

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	05/22/2024

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