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General NPI Number Information
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NPI Number | 1598056707
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Entity Type | Individual
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Provider Name | JUSTINE TAYLOR THEISEN M.A. CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 04/21/2011
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Last Update Date | 08/30/2016
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Provider Practice Location Address
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Address Line | 5811 BAMBOO DRIVE
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City | FORT PIERCE
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State | FL
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Zip | 34982-3758
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Country | US
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Telephone | 772-242-3187
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Fax | 772-494-7262
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Provider Business Mailing Address
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Address Line | 5811 BAMBOO DRIVE
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City | FORT PIERCE
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State | FL
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Zip | 34982-3758
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Country | US
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Telephone | 772-242-3187
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Fax | 772-494-7262
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | SA10918
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License Number State | FL
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