=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003124090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PERSEPHONE BLAIR-KNIGHT M ED. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2010
-----------------------------------------------------
Last Update Date | 03/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9280 HAMMOCKS BLVD SUITE # 103
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33196-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-385-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10405 SW 153RD CT APT 6
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33196-2721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-383-3710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA 11422
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------