=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417524901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPARK YOUR SPEECH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2021
-----------------------------------------------------
Last Update Date | 06/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2245 GREENRIDGE RD APT 201
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-870-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2245 GREENRIDGE RD APT 201
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-870-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MEGAN ELIZABETH JONES
-----------------------------------------------------
Credential | MA, CCC-SLP
-----------------------------------------------------
Telephone | 843-870-1536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------