Healthcare Provider Details

I. General information

NPI: 1497112171
Provider Name (Legal Business Name): LACTATION, EARLY INTERVENTION, AND FEEDING THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 SE HIBISCUS AVE
STUART FL
34996-3602
US

IV. Provider business mailing address

615 SE HIBISCUS AVE
STUART FL
34996-3602
US

V. Phone/Fax

Practice location:
  • Phone: 772-485-4357
  • Fax:
Mailing address:
  • Phone: 772-485-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-111185
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 11146
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: AMELIA FRY
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MS, CCC-SLP, IBCLC
Phone: 772-485-4357