Healthcare Provider Details

I. General information

NPI: 1720524598
Provider Name (Legal Business Name): PEDIATRIC SPEECH LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 09/01/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11350 PEMBROOKE SQ STE 313
WALDORF MD
20603-4809
US

IV. Provider business mailing address

11350 PEMBROOKE SQ STE 313
WALDORF MD
20603-4809
US

V. Phone/Fax

Practice location:
  • Phone: 301-885-0033
  • Fax:
Mailing address:
  • Phone: 301-885-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number08341
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP000879
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. QUINTINA MARIA BRISCOE
Title or Position: SPEECH-LANGUAGE PATHOLOGIST/ OWNER
Credential: M.S. CCC-SLP
Phone: 301-885-0033