Provider Demographics
NPI:1285121194
Name:PATHWAY SPEECH THERAPY LLC
Entity type:Organization
Organization Name:PATHWAY SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELLECIA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:DECOUTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-654-4959
Mailing Address - Street 1:2035 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7612
Mailing Address - Country:US
Mailing Address - Phone:503-654-4959
Mailing Address - Fax:503-437-9454
Practice Address - Street 1:2035 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7612
Practice Address - Country:US
Practice Address - Phone:503-654-4959
Practice Address - Fax:503-437-9454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15632235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500744169Medicaid
ORR202809OtherPTAN