Healthcare Provider Details

I. General information

NPI: 1679656409
Provider Name (Legal Business Name): INTERCEPT SPEECH AND LANGUAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E FRY BLVD SUITE #1
SIERRA VISTA AZ
85635-2600
US

IV. Provider business mailing address

13428 MAXELLA AVE # 228
MARINA DEL REY CA
90292-5620
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-8258
  • Fax: 520-459-8619
Mailing address:
  • Phone: 520-459-8258
  • Fax: 520-459-8619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberSLP4673
License Number StateAZ

VIII. Authorized Official

Name: MS. CORNETA E. KELLEY
Title or Position: OWNER
Credential: M.A.,CCC-SLP
Phone: 520-459-8258