Provider Demographics
NPI:1902143076
Name:BLOOMINGTON PEDIATRIC SPEECH THERAPY LLC
Entity Type:Organization
Organization Name:BLOOMINGTON PEDIATRIC SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:DOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:646-298-5246
Mailing Address - Street 1:1441 S FENBROOK LN
Mailing Address - Street 2:SUITE 400D
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4176
Mailing Address - Country:US
Mailing Address - Phone:646-298-5246
Mailing Address - Fax:
Practice Address - Street 1:1441 S FENBROOK LN
Practice Address - Street 2:SUITE 400D
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4176
Practice Address - Country:US
Practice Address - Phone:646-298-5246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005155A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty