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General NPI Number Information
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NPI Number | 1245787480
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Entity Type | Organization
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Legal Business Name | SPEECH SPARK SERVICES, LLC
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Dates
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Enumeration Date | 09/06/2016
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Last Update Date | 12/07/2016
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Provider Practice Location Address
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Address Line | 1924 SINCLAIR DR
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City | DE PERE
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State | WI
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Zip | 54115-7530
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Country | US
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Telephone | 920-403-0103
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Fax | 888-631-0117
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Provider Business Mailing Address
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Address Line | 1924 SINCLAIR DR
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City | DE PERE
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State | WI
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Zip | 54115-7530
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Country | US
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Telephone | 920-403-0103
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Fax | 888-631-0117
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST
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Name | BETH DOLAR
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Credential | M.S. CCC-SLP
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Telephone | 920-403-0103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2614-154
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License Number State | WI
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