Provider Demographics
NPI:1053799833
Name:EXCEPTIONAL EQUESTRIANS OF THE MISSOURI VALLEY, INC.
Entity type:Organization
Organization Name:EXCEPTIONAL EQUESTRIANS OF THE MISSOURI VALLEY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN. MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:SLP-A
Authorized Official - Phone:636-390-2141
Mailing Address - Street 1:785 YELLOW FINCH LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5457
Mailing Address - Country:US
Mailing Address - Phone:636-390-2141
Mailing Address - Fax:636-239-7011
Practice Address - Street 1:785 YELLOW FINCH LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-5457
Practice Address - Country:US
Practice Address - Phone:636-390-2141
Practice Address - Fax:636-239-7011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150097372355S0801X
MO2011018918235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty