Healthcare Provider Details

I. General information

NPI: 1104410893
Provider Name (Legal Business Name): JOSHUA PERDUE CCC'S-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1699 SE LYNGATE DR
PORT SAINT LUCIE FL
34952-5016
US

IV. Provider business mailing address

1699 SE LYNGATE DR
PORT SAINT LUCIE FL
34952-5016
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-9990
  • Fax:
Mailing address:
  • Phone: 772-335-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA18003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: