Healthcare Provider Details

I. General information

NPI: 1043936941
Provider Name (Legal Business Name): SPEECH CENTER INDIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 S TWYCKENHAM DR
SOUTH BEND IN
46614-1440
US

IV. Provider business mailing address

2616 S TWYCKENHAM DR
SOUTH BEND IN
46614-1440
US

V. Phone/Fax

Practice location:
  • Phone: 574-350-3943
  • Fax:
Mailing address:
  • Phone: 574-350-3943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAIZY YORMARK
Title or Position: SPEECH THERAPIST
Credential:
Phone: 574-350-3943