=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790547875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST COAST SPEECH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2024
-----------------------------------------------------
Last Update Date | 01/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30503 QUILLEN POINT RD
-----------------------------------------------------
City | OCEAN VIEW
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19970-2739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-253-7438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30503 QUILLEN POINT RD
-----------------------------------------------------
City | OCEAN VIEW
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19970-2739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-253-7438
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | NICHOLAS BOLLINGER
-----------------------------------------------------
Credential | M.S. CCC-SLP
-----------------------------------------------------
Telephone | 717-253-7438
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------