Healthcare Provider Details

I. General information

NPI: 1972058121
Provider Name (Legal Business Name): CHRISTINE SUSAN EADS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17208 LONG BOAT LN
ORLANDO FL
32820-2701
US

IV. Provider business mailing address

17208 LONG BOAT LN
ORLANDO FL
32820-2701
US

V. Phone/Fax

Practice location:
  • Phone: 208-830-2143
  • Fax:
Mailing address:
  • Phone: 208-830-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 12984
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP 23994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: