=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194543728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2024
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 DICKINSON RD
-----------------------------------------------------
City | KENDALL PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08824-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-609-7671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 DICKINSON RD
-----------------------------------------------------
City | KENDALL PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08824-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-609-7671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | ASHLEY WOLLER
-----------------------------------------------------
Credential | MA, CCC-SLP, TSSLD
-----------------------------------------------------
Telephone | 732-609-7671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------