Healthcare Provider Details

I. General information

NPI: 1639555881
Provider Name (Legal Business Name): SPEECH PATHOLOGY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PROGRESS DR STE 2B
SHELTON CT
06484-6294
US

IV. Provider business mailing address

10 PROGRESS DR STE 2B
SHELTON CT
06484-6294
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number003727
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SAMORAJCZYK
Title or Position: BILLING
Credential:
Phone: 475-239-5512