Provider Demographics
NPI:1679186217
Name:SPROUT PEDIATRIC SPEECH THERAPY INC
Entity type:Organization
Organization Name:SPROUT PEDIATRIC SPEECH THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CUBBAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP, CMT
Authorized Official - Phone:831-471-7344
Mailing Address - Street 1:9057 SOQUEL DRIVE
Mailing Address - Street 2:BUILDING A, SUITE CC
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003
Mailing Address - Country:US
Mailing Address - Phone:831-471-7344
Mailing Address - Fax:831-999-1131
Practice Address - Street 1:2042 BOBWHITE LN
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1853
Practice Address - Country:US
Practice Address - Phone:408-533-2339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty