Provider Demographics
NPI:1053309807
Name:FLORIDA STATE UNIVERSITY
Entity type:Organization
Organization Name:FLORIDA STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-644-8445
Mailing Address - Street 1:201 W BLOXHAM ST WARREN BUILDING
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32306-1200
Mailing Address - Country:US
Mailing Address - Phone:850-644-2238
Mailing Address - Fax:850-644-8994
Practice Address - Street 1:201 W BLOXHAM ST WARREN BUILDING
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32306-1200
Practice Address - Country:US
Practice Address - Phone:850-644-2238
Practice Address - Fax:850-644-8994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 5640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL880606300Medicaid