Provider Demographics
NPI:1144636986
Name:WESTERN KENTUCKY UNIVERSITY SPEECH CLINIC
Entity type:Organization
Organization Name:WESTERN KENTUCKY UNIVERSITY SPEECH CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, CCC-SLP
Authorized Official - Phone:270-745-2183
Mailing Address - Street 1:104 ALUMNI AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-3404
Mailing Address - Country:US
Mailing Address - Phone:270-745-4232
Mailing Address - Fax:270-745-4233
Practice Address - Street 1:104 ALUMNI AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3404
Practice Address - Country:US
Practice Address - Phone:270-745-4232
Practice Address - Fax:270-745-4233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN KENTUCKY UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation