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General NPI Number Information
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NPI Number | 1407138613
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Entity Type | Organization
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Legal Business Name | LAKES REGION PEDIATRIC SPEECH SERVICES
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Dates
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Enumeration Date | 09/13/2011
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 372 HIO RIDGE RD
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City | BRIDGTON
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State | ME
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Zip | 04009-3449
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Country | US
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Telephone | 401-835-5368
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Fax |
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Provider Business Mailing Address
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Address Line | 372 HIO RIDGE RD
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City | BRIDGTON
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State | ME
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Zip | 04009-3449
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Country | US
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Telephone | 401-835-5368
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | SUSAN MURPHY
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Credential | MS CCC-SLP
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Telephone | 401-835-5368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SP1919
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License Number State | ME
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