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General NPI Number Information
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NPI Number | 1366947574
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Entity Type | Organization
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Legal Business Name | NEW LIFE SPEECH THERAPY
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Dates
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Enumeration Date | 03/28/2018
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Last Update Date | 03/28/2018
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Provider Practice Location Address
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Address Line | 1450 GLEN HAVEN DR
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City | MERRITT ISLAND
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State | FL
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Zip | 32952-5821
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Country | US
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Telephone | 321-917-0297
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Fax |
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Provider Business Mailing Address
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Address Line | 1450 GLEN HAVEN DR
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City | MERRITT ISLAND
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State | FL
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Zip | 32952-5821
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Country | US
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Telephone | 321-917-0297
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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 | MRS. LAURIE BURNETT
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Credential | M.S. CCC-SLP
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Telephone | 321-917-0297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | SA16056
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License Number State | FL
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