Healthcare Provider Details

I. General information

NPI: 1912614488
Provider Name (Legal Business Name): LIVELY SPEECH AND LANGUAGE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NATURE WALK PKWY UNIT 108
ST AUGUSTINE FL
32092-3065
US

IV. Provider business mailing address

111 NATURE WALK PKWY UNIT 108
ST AUGUSTINE FL
32092-3065
US

V. Phone/Fax

Practice location:
  • Phone: 904-729-6759
  • Fax: 904-490-8549
Mailing address:
  • Phone: 904-729-6759
  • Fax: 904-490-8549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. SARAH LIVELY
Title or Position: CEO & FOUNDER
Credential: CCC-SLP
Phone: 904-729-6759