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General NPI Number Information
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NPI Number | 1497112171
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Entity Type | Organization
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Legal Business Name | LACTATION, EARLY INTERVENTION, AND FEEDING THERAPIES
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Dates
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Enumeration Date | 01/26/2016
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Last Update Date | 03/15/2017
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Provider Practice Location Address
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Address Line | 615 SE HIBISCUS AVE
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City | STUART
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State | FL
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Zip | 34996-3602
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Country | US
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Telephone | 772-485-4357
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Fax |
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Provider Business Mailing Address
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Address Line | 615 SE HIBISCUS AVE
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City | STUART
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State | FL
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Zip | 34996-3602
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Country | US
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Telephone | 772-485-4357
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Fax |
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST
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Name | AMELIA FRY
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Credential | MS, CCC-SLP, IBCLC
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Telephone | 772-485-4357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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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 | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number | L-111185
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SA 11146
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License Number State | FL
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