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General NPI Number Information
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NPI Number | 1679656409
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Entity Type | Organization
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Legal Business Name | INTERCEPT SPEECH AND LANGUAGE, LLC
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 07/08/2009
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Provider Practice Location Address
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Address Line | 1201 E FRY BLVD SUITE #1
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-2600
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Country | US
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Telephone | 520-459-8258
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Fax | 520-459-8619
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Provider Business Mailing Address
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Address Line | 13428 MAXELLA AVE # 228
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5620
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Country | US
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Telephone | 520-459-8258
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Fax | 520-459-8619
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Authorized Official
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Title or Position | OWNER
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Name | MS. CORNETA E. KELLEY
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Credential | M.A.,CCC-SLP
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Telephone | 520-459-8258
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | SLP4673
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License Number State | AZ
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