Healthcare Provider Details

I. General information

NPI: 1215091392
Provider Name (Legal Business Name): TALK SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 US ROUTE 202
NORTH MONMOUTH ME
04265
US

IV. Provider business mailing address

PO BOX 55 392 US RTE 202
N MONMOUTH ME
04265-0055
US

V. Phone/Fax

Practice location:
  • Phone: 207-933-6813
  • Fax: 207-933-6726
Mailing address:
  • Phone: 207-933-6813
  • Fax: 207-933-6726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP844
License Number StateME

VIII. Authorized Official

Name: FAYE B. JEAN
Title or Position: PRESIDENT
Credential: M.A., CCC-SLP
Phone: 207-933-6813