=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972986172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEECH AND SWALLOWING SPECIALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2015
-----------------------------------------------------
Last Update Date | 07/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3208 CRAVEN BRANCH RD
-----------------------------------------------------
City | RAMSEUR
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27316-8490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-963-1043
-----------------------------------------------------
Fax | 336-615-8443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3208 CRAVEN BRANCH RD
-----------------------------------------------------
City | RAMSEUR
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27316-8490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-963-1043
-----------------------------------------------------
Fax | 336-615-8443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST/CEO
-----------------------------------------------------
Name | MRS. MARIA KOENIG
-----------------------------------------------------
Credential | M.ED., CCC-SLP
-----------------------------------------------------
Telephone | 336-963-1043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 4183
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------