Provider Demographics
NPI:1366979502
Name:SUPERCALIFRAGILISTIC SPEECH LANGUAGE THERAPY INC.
Entity type:Organization
Organization Name:SUPERCALIFRAGILISTIC SPEECH LANGUAGE THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:BRIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:203-500-0969
Mailing Address - Street 1:1204 MAIN ST STE 218
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1204 MAIN ST # 218
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3787
Practice Address - Country:US
Practice Address - Phone:203-208-8377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
13500248OtherCAQH