Provider Demographics
NPI:1205132123
Name:IOWA SPEECH THERAPY, LLC
Entity type:Organization
Organization Name:IOWA SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:319-533-2916
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-0425
Mailing Address - Country:US
Mailing Address - Phone:319-533-2916
Mailing Address - Fax:319-462-0546
Practice Address - Street 1:118 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-1871
Practice Address - Country:US
Practice Address - Phone:319-533-2916
Practice Address - Fax:319-462-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001793261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1873OtherMEDICARE PTAN