=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457069387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRING SPEECH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2022
-----------------------------------------------------
Last Update Date | 11/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2258 DUHON RD
-----------------------------------------------------
City | JENNINGS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70546-8608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-388-0850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2258 DUHON RD
-----------------------------------------------------
City | JENNINGS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70546-8608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-388-0850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALICIA KETTLER
-----------------------------------------------------
Credential | M.S. CCC/SLP
-----------------------------------------------------
Telephone | 337-388-0850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------