Provider Demographics
NPI:1053435727
Name:GRIFFIN-SOTAK, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:GRIFFIN-SOTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2888 CREST TER
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-4715
Mailing Address - Country:US
Mailing Address - Phone:239-464-4978
Mailing Address - Fax:
Practice Address - Street 1:2888 CREST TER
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-4715
Practice Address - Country:US
Practice Address - Phone:239-464-4978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012340235Z00000X
FLSA8202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891099500Medicaid
PASL012340OtherPA LICENSE