=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134414345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEASTAR SPEECH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2011
-----------------------------------------------------
Last Update Date | 06/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1255 LAKE PLAZA DR SUITE269
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-538-6027
-----------------------------------------------------
Fax | 719-344-2328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1255 LAKE PLAZA DR SUITE269
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-538-6027
-----------------------------------------------------
Fax | 719-344-2328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MRS. TAMARA ANN GORMAN
-----------------------------------------------------
Credential | MS, CCC-SLP
-----------------------------------------------------
Telephone | 719-538-6027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | 01129463
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------