Provider Demographics
NPI:1316435571
Name:TILLAMOOK SPEECH LANGUAGE LEARNING CENTER
Entity type:Organization
Organization Name:TILLAMOOK SPEECH LANGUAGE LEARNING CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:ST.JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:503-341-1571
Mailing Address - Street 1:210 CAPES DR W
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9380
Mailing Address - Country:US
Mailing Address - Phone:503-341-1571
Mailing Address - Fax:
Practice Address - Street 1:800 MAIN AVE STE B
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3760
Practice Address - Country:US
Practice Address - Phone:503-341-1571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13436235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty