=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780102905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKESHORE SPEECH AND LANGUAGE THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 09/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 PALOS VERDE DR
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-9070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-540-9041
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 PALOS VERDE DR
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-9070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | JENNIFER MICHELLE PATEL
-----------------------------------------------------
Credential | MS, CCC-SLP
-----------------------------------------------------
Telephone | 602-540-9041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 11079
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------