Healthcare Provider Details

I. General information

NPI: 1528591302
Provider Name (Legal Business Name): FRESH START SPEECH THERAPY SERVICES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9957 MOORINGS DR STE 301
JACKSONVILLE FL
32257-2415
US

IV. Provider business mailing address

9957 MOORINGS DR STE 301
JACKSONVILLE FL
32257-2415
US

V. Phone/Fax

Practice location:
  • Phone: 904-652-6165
  • Fax: 833-241-4607
Mailing address:
  • Phone: 904-652-6165
  • Fax: 833-241-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KHALILAH MIGNON MARQUES
Title or Position: DIRECTOR, MANAGER
Credential: M.A. CCC-SLP
Phone: 904-652-6165