Provider Demographics
NPI:1730619875
Name:RENEW SPEECH LANGUAGE PATHOLOGY
Entity type:Organization
Organization Name:RENEW SPEECH LANGUAGE PATHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DORINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-472-8987
Mailing Address - Street 1:8644 WATER FALL DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-2033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8644 WATER FALL DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-2033
Practice Address - Country:US
Practice Address - Phone:240-472-8987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty