Healthcare Provider Details

I. General information

NPI: 1881627982
Provider Name (Legal Business Name): BETH R POE CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12276 SAN JOSE BLVD
JACKSONVILLE FL
32223-8628
US

IV. Provider business mailing address

4185 VENETIA BLVD
JACKSONVILLE FL
32210-8505
US

V. Phone/Fax

Practice location:
  • Phone: 904-886-3228
  • Fax:
Mailing address:
  • Phone: 401-864-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP00723
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: