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General NPI Number Information
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NPI Number | 1881021749
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Entity Type | Organization
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Legal Business Name | ATLANTIC SPEECH THERAPY
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Dates
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Enumeration Date | 10/08/2013
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Last Update Date | 10/08/2013
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Provider Practice Location Address
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Address Line | 11512 LAKE MEAD AVE UNIT 604
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City | JACKSONVILLE
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State | FL
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Zip | 32256-9686
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Country | US
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Telephone | 904-652-5408
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Fax |
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Provider Business Mailing Address
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Address Line | 11512 LAKE MEAD AVE UNIT 604
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City | JACKSONVILLE
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State | FL
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Zip | 32256-9686
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/OWNER
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Name | JESSICA OTTO
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Credential |
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Telephone | 904-652-5408
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 15996
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License Number State | FL
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