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General NPI Number Information
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NPI Number | 1578957684
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Entity Type | Organization
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Legal Business Name | 29TH STREET THERAPY
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Dates
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Enumeration Date | 03/26/2015
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Last Update Date | 03/26/2015
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Provider Practice Location Address
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Address Line | 1211 S 29TH ST
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City | CHICKASHA
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State | OK
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Zip | 73018-9651
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Country | US
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Telephone | 405-224-0002
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Fax | 405-224-0133
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Provider Business Mailing Address
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Address Line | 1211 S 29TH ST
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City | CHICKASHA
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State | OK
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Zip | 73018-9651
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Country | US
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Telephone | 405-224-0002
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Fax | 405-224-0133
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Authorized Official
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Title or Position | SPEECH-LANGUAGE PATHOLOGIST
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Name | MS. DANIELLE EVA KLEVGARD
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Credential | M.A. CCC-SLP
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Telephone | 405-669-0908
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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 | 4251
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License Number State | OK
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