MEDICARE: SPEECH SPARK THERAPY SERVICES 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	2017016066	MO

General Provider Information

NPI Number	:	1497241988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPEECH SPARK THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	1241 STRASSNER DR APT 1402
Second Line	:
City	:	BRENTWOOD
State	:	MO
Zip	:	63144-1876
Country	:	US
Telephone Number	:	904-303-0183
Fax Number	:

Provider Business Practice Location Address
First Line	:	8764 ROSALIE AVE UNIT 440162
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63144-5026
Country	:	US
Telephone Number	:	314-690-8521
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	ELIZABETH J LIAN
Credential	:	CCC-SLP
Telephone Number	:	314-690-8521

Provider Enumeration Date	:	07/08/2018
Last Update Date	:	07/31/2018

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