Provider Demographics
NPI:1548523673
Name:NORTHEASTERN SPEECH THERAPY, PLLC
Entity type:Organization
Organization Name:NORTHEASTERN SPEECH THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:POTEETE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:918-931-8941
Mailing Address - Street 1:PO BOX 1612
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1612
Mailing Address - Country:US
Mailing Address - Phone:918-931-8941
Mailing Address - Fax:
Practice Address - Street 1:18771 S 525 RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0518
Practice Address - Country:US
Practice Address - Phone:918-931-8941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3626235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200285740Medicaid