Provider Demographics
NPI:1427440510
Name:SPEAK THERAPY GROUP LLC
Entity type:Organization
Organization Name:SPEAK THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:915-526-1211
Mailing Address - Street 1:PO BOX 744
Mailing Address - Street 2:
Mailing Address - City:CHAMBERINO
Mailing Address - State:NM
Mailing Address - Zip Code:88027-0744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 LOPEZ RD
Practice Address - Street 2:
Practice Address - City:CHAMBERINO
Practice Address - State:NM
Practice Address - Zip Code:88002
Practice Address - Country:US
Practice Address - Phone:915-526-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5455235Z00000X
TX105155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM50579339Medicaid