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General NPI Number Information
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NPI Number | 1710255492
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Entity Type | Organization
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Legal Business Name | YOUR SPEECH THERAPIST, INC.
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Dates
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Enumeration Date | 12/08/2011
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Last Update Date | 06/04/2012
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Provider Practice Location Address
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Address Line | 8178 SANDPIPER GLEN DRIVE
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City | LAKE WORTH
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State | FL
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Zip | 33467-6946
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Country | US
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Telephone | 954-778-8867
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Fax |
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Provider Business Mailing Address
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Address Line | 8178 SANDPIPER GLEN DRIVE
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City | LAKE WORTH
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State | FL
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Zip | 33467-6946
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Country | US
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Telephone | 954-778-8876
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Fax |
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Authorized Official
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Title or Position | PRES
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Name | MARC H MITNICK
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Credential | MS/CCC-SLP
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Telephone | 954-778-8876
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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 | SA2045
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License Number State | FL
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