Provider Demographics
NPI:1053972703
Name:THE SPEECH LAB, LLC
Entity type:Organization
Organization Name:THE SPEECH LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:FAITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-698-5560
Mailing Address - Street 1:200 WEKIVA CV
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-4763
Mailing Address - Country:US
Mailing Address - Phone:918-698-5560
Mailing Address - Fax:
Practice Address - Street 1:898 HIGHWAY 98 E
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2700
Practice Address - Country:US
Practice Address - Phone:918-698-5560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty