Healthcare Provider Details

I. General information

NPI: 1295512267
Provider Name (Legal Business Name): INTERAACTIVE SPEECH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3222 W FULLER DR
ANTHEM AZ
85086-6004
US

IV. Provider business mailing address

3222 W FULLER DR
ANTHEM AZ
85086-6004
US

V. Phone/Fax

Practice location:
  • Phone: 847-596-0445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SARAH FARISON
Title or Position: OWNER
Credential: MS CCC-SLP
Phone: 847-596-0445