=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215091392
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TALK SHOP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 09/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 392 US ROUTE 202
-----------------------------------------------------
City | NORTH MONMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-933-6813
-----------------------------------------------------
Fax | 207-933-6726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 55 392 US RTE 202
-----------------------------------------------------
City | N MONMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04265-0055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-933-6813
-----------------------------------------------------
Fax | 207-933-6726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | FAYE B. JEAN
-----------------------------------------------------
Credential | M.A., CCC-SLP
-----------------------------------------------------
Telephone | 207-933-6813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP844
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------