Provider Demographics
NPI:1730420936
Name:SPEECH PATHOLOGY ASSOCIATES INC
Entity type:Organization
Organization Name:SPEECH PATHOLOGY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MS-CCC-SLP
Authorized Official - Phone:616-450-9668
Mailing Address - Street 1:3951 BRIDGESTONE DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-1378
Mailing Address - Country:US
Mailing Address - Phone:616-954-1810
Mailing Address - Fax:
Practice Address - Street 1:1810 E BELTLINE AVE SE
Practice Address - Street 2:DEVOS COMMUNICATION CENTER, 225A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5951
Practice Address - Country:US
Practice Address - Phone:616-954-1810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00972133OtherASHA CERTIFICATION