Provider Demographics
NPI:1649672478
Name:SPEECH LANGUAGE PATHOLOGIST
Entity type:Organization
Organization Name:SPEECH LANGUAGE PATHOLOGIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH AND LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:609-915-7637
Mailing Address - Street 1:111 CAIN CT
Mailing Address - Street 2:
Mailing Address - City:BELLE MEAD
Mailing Address - State:NJ
Mailing Address - Zip Code:08502-6405
Mailing Address - Country:US
Mailing Address - Phone:609-915-7637
Mailing Address - Fax:
Practice Address - Street 1:111 CAIN CT
Practice Address - Street 2:
Practice Address - City:BELLE MEAD
Practice Address - State:NJ
Practice Address - Zip Code:08502-6405
Practice Address - Country:US
Practice Address - Phone:609-915-7637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00647200251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)