=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134654262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDS SPEAK THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2017
-----------------------------------------------------
Last Update Date | 04/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 MIDTOWN CIR
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-587-9021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 MIDTOWN CIR
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-587-9021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RACHEL BREITOWITZ
-----------------------------------------------------
Credential | SLP
-----------------------------------------------------
Telephone | 347-587-9021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------