=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235789496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC SPEECH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2019
-----------------------------------------------------
Last Update Date | 04/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 523 HIILEI PL
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-1522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-280-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 791659
-----------------------------------------------------
City | PAIA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96779-1659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-280-2732
-----------------------------------------------------
Fax | 808-793-2307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. TRISHA RYAN
-----------------------------------------------------
Credential | MS CCC-SLP
-----------------------------------------------------
Telephone | 808-280-2732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------