Provider Demographics
NPI:1154019842
Name:IVY LEAGUE SPEECH THERAPY CENTER
Entity type:Organization
Organization Name:IVY LEAGUE SPEECH THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:EMMA
Authorized Official - Last Name:TAVELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:516-425-9897
Mailing Address - Street 1:309 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4312
Mailing Address - Country:US
Mailing Address - Phone:516-425-9897
Mailing Address - Fax:
Practice Address - Street 1:309 CHERRY LN
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4312
Practice Address - Country:US
Practice Address - Phone:516-425-9897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty