MEDICARE: NEW KENT SPEECH PATHOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1932787728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW KENT SPEECH PATHOLOGY, LLC

Provider Business Mailing Address
First Line	:	9081 DEERLAKE DR
Second Line	:
City	:	NEW KENT
State	:	VA
Zip	:	23124-3031
Country	:	US
Telephone Number	:	804-836-6935
Fax Number	:

Provider Business Practice Location Address
First Line	:	3215 ROCK CREEK VILLA DR STE 6
Second Line	:
City	:	QUINTON
State	:	VA
Zip	:	23141-1656
Country	:	US
Telephone Number	:	804-836-6935
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	MRS. COURTNEY LEIGH SPATES
Credential	:	M.S., CCC-SLP
Telephone Number	:	804-836-6935

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/06/2021

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