=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659860997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOTOR MOUTH SPEECH THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2018
-----------------------------------------------------
Last Update Date | 05/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7629 SONORA VIEW ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89149-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-250-5349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7629 SONORA VIEW ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89149-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-250-5349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. SARAH GRACE COHEN
-----------------------------------------------------
Credential | M.S. CCC/SLP
-----------------------------------------------------
Telephone | 702-250-5349
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP-1023
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------