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General NPI Number Information
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NPI Number | 1114289352
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Entity Type | Organization
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Legal Business Name | SEAGULL VENTURES LLC
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Dates
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Enumeration Date | 06/13/2012
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Last Update Date | 08/15/2012
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Provider Practice Location Address
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Address Line | 19 MEADOW RIDGE LN
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City | NEW MILFORD
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State | CT
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Zip | 06776-3740
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Country | US
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Telephone | 203-947-5782
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Fax |
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Provider Business Mailing Address
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Address Line | 19 MEADOW RIDGE LN
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City | NEW MILFORD
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State | CT
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Zip | 06776-3740
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Country | US
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Telephone | 203-947-5782
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Fax |
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Authorized Official
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Title or Position | OWNER/SLP
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Name | MRS. ALISON WALDMANN
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Credential | MSCCCSLP
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Telephone | 203-947-5782
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 003097
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License Number State | CT
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