=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427657717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J. SILLS, SPEECH-LANGUAGE PATHOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2020
-----------------------------------------------------
Last Update Date | 10/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6883 KIMBERLY LN
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14047-9509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-481-7902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6883 KIMBERLY LN
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14047-9509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-481-7902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. JESSICA M SILLS
-----------------------------------------------------
Credential | SLP
-----------------------------------------------------
Telephone | 716-481-7902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------