Provider Demographics
NPI:1386768208
Name:PEDIATRIC SPEECH & LANGUAGE PATHOLOGIST, INC.
Entity type:Organization
Organization Name:PEDIATRIC SPEECH & LANGUAGE PATHOLOGIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:DOLL
Authorized Official - Suffix:
Authorized Official - Credentials:MED CCC-SLP
Authorized Official - Phone:407-318-7312
Mailing Address - Street 1:850 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6808
Mailing Address - Country:US
Mailing Address - Phone:407-318-7312
Mailing Address - Fax:407-428-6154
Practice Address - Street 1:850 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6808
Practice Address - Country:US
Practice Address - Phone:407-318-7312
Practice Address - Fax:407-428-6154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 3688235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8830509Medicaid