Healthcare Provider Details

I. General information

NPI: 1457690166
Provider Name (Legal Business Name): LAURA THEOBALD SPEECH THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 SAGAMORE RD
RYE NH
03870-2035
US

IV. Provider business mailing address

PO BOX 1042
RYE NH
03870-1042
US

V. Phone/Fax

Practice location:
  • Phone: 207-590-9194
  • Fax:
Mailing address:
  • Phone: 207-590-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number0649
License Number StateNH

VIII. Authorized Official

Name: MS. LAURA THEOBALD
Title or Position: MEMBER/MANAGER
Credential: MS CCC-SLP
Phone: 207-590-9194