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General NPI Number Information
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NPI Number | 1255872834
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Entity Type | Organization
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Legal Business Name | BLUE JELLYFISH LLC
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Dates
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Enumeration Date | 03/15/2017
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Last Update Date | 03/17/2017
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Provider Practice Location Address
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Address Line | 11241 SKILIFT CT UNIT A
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City | COLUMBIA
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State | MD
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Zip | 21044-3094
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Country | US
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Telephone | 410-733-1405
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Fax |
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Provider Business Mailing Address
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Address Line | 5525 TWIN KNOLLS RD STE 325
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City | COLUMBIA
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State | MD
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Zip | 21045-3203
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Country | US
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Telephone | 410-733-1405
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Fax |
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Authorized Official
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Title or Position | SPEECH-LANGUAGE PATHOLOGIST
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Name | MS. ANNE MOIRA HASTING
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Credential | M.S., CCC-SLP
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Telephone | 410-733-1405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number | 06143
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License Number State | MD
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