=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316106065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLEN-CLARK SPEECH/LANGUAGE REHAB. SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2008
-----------------------------------------------------
Last Update Date | 06/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 COLBY HILLS CIR
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40391-1661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-771-1593
-----------------------------------------------------
Fax | 859-744-0281
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 COLBY HILLS CIR
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40391-1661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-771-1593
-----------------------------------------------------
Fax | 859-744-0281
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MS. JAYNE M. ALLEN
-----------------------------------------------------
Credential | M.S.CCC/SLP
-----------------------------------------------------
Telephone | 859-771-1593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | KY1362
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------