=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598259376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEECH AT THE BEACH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2018
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 OAK AVE
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-651-6368
-----------------------------------------------------
Fax | 850-279-3298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1910 OAK AVE
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-651-6368
-----------------------------------------------------
Fax | 850-279-3298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | KRISTIN JOY FREELAND
-----------------------------------------------------
Credential | M.E.D., CCC-SLP
-----------------------------------------------------
Telephone | 419-651-6368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 12063
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------