Healthcare Provider Details

I. General information

NPI: 1467060459
Provider Name (Legal Business Name): SPEECH PATHOLOGY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BEARD SAWMILL RD STE 282
SHELTON CT
06484-6175
US

IV. Provider business mailing address

100 BEARD SAWMILL RD STE 282
SHELTON CT
06484-6175
US

V. Phone/Fax

Practice location:
  • Phone: 475-239-5512
  • Fax: 203-888-0352
Mailing address:
  • Phone: 475-239-5512
  • Fax: 203-888-0352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER SAMORAJCZYK
Title or Position: BILLING/OFFICE
Credential:
Phone: 475-239-5512