=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407093867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUTTERCUP SPEECH THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2009
-----------------------------------------------------
Last Update Date | 01/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4825 MARSHALL DR E
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-760-8980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4825 MARSHALL DR E
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-760-8980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTAN TOMAKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 607-760-8980
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------