=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669366696
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALL AGES SPEECH THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2025
-----------------------------------------------------
Last Update Date | 06/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 5TH ST STE 3
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-3480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-289-1838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 DESCANSO RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87508-9125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-720-8293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MS CCC-SLP
-----------------------------------------------------
Name | MR. JACOB MATTHEW OSBORN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 765-720-8293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------