Healthcare Provider Details

I. General information

NPI: 1063649499
Provider Name (Legal Business Name): SPACE COAST SPEECH AND LANGUAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 06/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W EAU GALLIE BLVD
MELBOURNE FL
32934-3285
US

IV. Provider business mailing address

741 DINNER ST NE
PALM BAY FL
32907-2034
US

V. Phone/Fax

Practice location:
  • Phone: 321-220-9405
  • Fax:
Mailing address:
  • Phone: 321-220-9405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA3000X
TaxonomyAugmentative Communication Clinic/Center
License NumberSA9802
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberSA9802
License Number StateFL

VIII. Authorized Official

Name: MRS. CHRISTINE LYNN CAREY
Title or Position: OWNER/SPEECH LANGUAGE PATHOLOGIST
Credential: MA, CCC-SLP
Phone: 321-220-9405