=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861173197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KODIAK CUBS SPEECH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2023
-----------------------------------------------------
Last Update Date | 07/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 452 LILLY DRIVE
-----------------------------------------------------
City | KODIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99615-9961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-395-7886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 591
-----------------------------------------------------
City | KODIAK
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99615-0591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-654-9498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | ADRIENNE CHAMBERS
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 907-654-9498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------