=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336649888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMALL TALK SPEECH AND LANGUAGE SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 02/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7950 E ACOMA DR STE 105
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-495-9324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4236
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85261-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-495-9324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, THERAPIST
-----------------------------------------------------
Name | KIM PADGETT MARYHEW
-----------------------------------------------------
Credential | SPEECH LANGUAGE PATH
-----------------------------------------------------
Telephone | 480-495-9324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP4521
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------