=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215500210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEECH LAB THERAPY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2021
-----------------------------------------------------
Last Update Date | 07/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3837 SAN ISIDRO CIR
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34772-8377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-300-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3837 SAN ISIDRO CIR
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34772-8377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-300-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JOSEPH GIOVANNI GAUTIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 321-300-9320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------