Healthcare Provider Details

I. General information

NPI: 1336632348
Provider Name (Legal Business Name): HOLISTIC SPEECH & LANGUAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 SW PELTON PL
BEND OR
97702-1207
US

IV. Provider business mailing address

635 SW PELTON PL
BEND OR
97702-1207
US

V. Phone/Fax

Practice location:
  • Phone: 206-409-9964
  • Fax: 206-905-0104
Mailing address:
  • Phone: 206-409-9964
  • Fax: 206-905-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberLL60023213
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TIFFANY (TY) LOCKHART
Title or Position: OWNER/SLP
Credential: M.A., CCC-SLP
Phone: 206-409-9964