Provider Demographics
NPI:1316723018
Name:THE COLORFUL SPOT PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:THE COLORFUL SPOT PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:WIKUM
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:920-857-7925
Mailing Address - Street 1:4906 WHISPERING CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-2503
Mailing Address - Country:US
Mailing Address - Phone:920-857-7925
Mailing Address - Fax:
Practice Address - Street 1:4906 WHISPERING CREEK CT
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-2503
Practice Address - Country:US
Practice Address - Phone:920-857-7925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty