=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497385520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENRI FORT MS,CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2020
-----------------------------------------------------
Last Update Date | 11/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1992 LEWIS TURNER BLVD SUITE 1067 #255
-----------------------------------------------------
City | FORT WALTON BEEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-830-3314
-----------------------------------------------------
Fax | 850-904-0355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 BLACK BEAR CIR
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-1202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-830-3314
-----------------------------------------------------
Fax | 850-904-0355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number | 18378
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA18378
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------