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General NPI Number Information
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NPI Number | 1477908390
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Entity Type | Organization
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Legal Business Name | 21C SPEECH- LANGUAGE TELEPRACTICE
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Dates
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Enumeration Date | 04/28/2016
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Last Update Date | 04/28/2016
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Provider Practice Location Address
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Address Line | 543 GENERAL CRUFT DR
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City | RICHMOND
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State | KY
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Zip | 40475-7520
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Country | US
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Telephone | 859-582-3659
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Fax |
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Provider Business Mailing Address
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Address Line | 543 GENERAL CRUFT DR
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City | RICHMOND
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State | KY
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Zip | 40475-7520
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Country | US
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Telephone | 859-582-3659
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Fax |
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST/ OWNER
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Name | MRS. JENNIFER LEIGH GROSS
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Credential | M.A. CCC/ SLP
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Telephone | 859-582-3659
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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 | 2151
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License Number State | KY
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