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General NPI Number Information
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NPI Number | 1447489240
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Entity Type | Organization
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Legal Business Name | FIRST COAST SPEECH & LANGUAGE SERVICES, LLC
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Dates
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Enumeration Date | 07/14/2009
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Last Update Date | 07/14/2009
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Provider Practice Location Address
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Address Line | 1571 RIVERTRACE DR
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-7778
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Country | US
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Telephone | 904-631-1525
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Fax | 904-215-1242
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Provider Business Mailing Address
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Address Line | 1571 RIVERTRACE DR
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-7778
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Country | US
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Telephone | 904-631-1525
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Fax | 904-215-1242
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MRS. TERESA ELAINE GRADY
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Credential | M.S. CCC-SLP
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Telephone | 904-631-1525
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA6782
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License Number State | FL
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