=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902629587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PONTE VEDRA SPEECH THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 TAVERNIER DR UNIT B
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-0677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-844-3136
-----------------------------------------------------
Fax | 904-789-6295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 TAVERNIER DR UNIT B
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-0677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-844-3136
-----------------------------------------------------
Fax | 904-789-6295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SONYA MARIE OLSEN
-----------------------------------------------------
Credential | MS, CCC-SLP
-----------------------------------------------------
Telephone | 904-844-3136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------