=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033670468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN BRICKETT SPEECH THERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2019
-----------------------------------------------------
Last Update Date | 03/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 308 RACEBROOK ROAD, UNIT A
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06477-0647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-250-9663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 382 S MAIN ST
-----------------------------------------------------
City | CHESHIRE
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06410-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-250-9663
-----------------------------------------------------
Fax | 203-699-9641
-----------------------------------------------------
=====================================================
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 | 004811
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------