=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770967689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE COMMUNICATION STATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2015
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 S MAIN ST SUITE 4
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-897-7072
-----------------------------------------------------
Fax | 870-932-1899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 S MAIN ST SUITE 4
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-897-7072
-----------------------------------------------------
Fax | 870-932-1899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. NITA STILLWELL
-----------------------------------------------------
Credential | M.S, CCC-SLP
-----------------------------------------------------
Telephone | 870-897-7072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP#1417
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------