Provider Demographics
NPI:1336919554
Name:SPEECH FORMULA THERAPEUTICS, LLC
Entity type:Organization
Organization Name:SPEECH FORMULA THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:A'KAILA
Authorized Official - Middle Name:MONAE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:843-812-9751
Mailing Address - Street 1:PO BOX 292181
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-0037
Mailing Address - Country:US
Mailing Address - Phone:843-812-9751
Mailing Address - Fax:
Practice Address - Street 1:3015 CHIPPING LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2012
Practice Address - Country:US
Practice Address - Phone:843-812-9751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty