=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487531117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIP SWALLOW SPEECH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2025
-----------------------------------------------------
Last Update Date | 08/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 MILL ST # 8
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-719-6696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 MILL ST # 8
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04011-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-719-6696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. GINA VANDEUSEN
-----------------------------------------------------
Credential | MA,CCC-SLP
-----------------------------------------------------
Telephone | 207-719-6696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------