=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073244364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MOBILE SPEECH CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2022
-----------------------------------------------------
Last Update Date | 06/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 N PEARL AVE
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64801-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-699-4334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 226 N PEARL AVE
-----------------------------------------------------
City | JOPLIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64801-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-699-4334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | KELLY CLARK
-----------------------------------------------------
Credential | MS, CCC-SLP
-----------------------------------------------------
Telephone | 617-699-4334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------