Healthcare Provider Details

I. General information

NPI: 1154518785
Provider Name (Legal Business Name): SPEECH PATHOLOGY SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 CARTER RD
AUSTIN AR
72007-9331
US

IV. Provider business mailing address

286 CARTER RD
AUSTIN AR
72007-9331
US

V. Phone/Fax

Practice location:
  • Phone: 501-690-0242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1117
License Number StateAR

VIII. Authorized Official

Name: MRS. LISA MARTIN
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S., CCC-SLP
Phone: 501-690-0242