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General NPI Number Information
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NPI Number | 1053972703
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Entity Type | Organization
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Legal Business Name | THE SPEECH LAB, LLC
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Dates
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Enumeration Date | 06/24/2019
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 898 HIGHWAY 98 E
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City | DESTIN
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State | FL
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Zip | 32541-2700
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Country | US
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Telephone | 918-698-5560
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Fax |
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Provider Business Mailing Address
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Address Line | 200 WEKIVA CV
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City | DESTIN
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State | FL
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Zip | 32541-4763
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Country | US
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Telephone | 918-698-5560
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JONATHAN T FAITH
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Credential |
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Telephone | 918-698-5560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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