Healthcare Provider Details

I. General information

NPI: 1760520613
Provider Name (Legal Business Name): CHILDHOOD SPEECH & LANGUAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 152ND AVE NE
REDMOND WA
98052-5552
US

IV. Provider business mailing address

2721 152ND AVE NE
REDMOND WA
98052-5552
US

V. Phone/Fax

Practice location:
  • Phone: 425-867-0475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL00002785
License Number StateWA

VIII. Authorized Official

Name: RYAN J CONLEY
Title or Position: DIRECTOR
Credential: CCC-SLP
Phone: 425-867-0475