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General NPI Number Information
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NPI Number | 1447691910
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Entity Type | Organization
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Legal Business Name | LILY PEARL SPEECH THERAPY, LLC
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Dates
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Enumeration Date | 07/12/2013
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Last Update Date | 07/12/2013
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Provider Practice Location Address
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Address Line | 824 W 4TH ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-5012
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Country | US
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Telephone | 812-322-0052
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Fax |
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Provider Business Mailing Address
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Address Line | 824 W. 4TH ST.
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City | BLOOMINGTON
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State | IN
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Zip | 47404
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Country | US
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Telephone | 812-322-0052
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUZANNAH MARGARET EDGAR
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Credential | MA, CCC-SLP
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Telephone | 812-322-0052
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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 | 22005087A
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License Number State | IN
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