Provider Demographics
NPI:1427566082
Name:SOUTH JERSEY SPEECH LANGUAGE PATHOLOGY
Entity type:Organization
Organization Name:SOUTH JERSEY SPEECH LANGUAGE PATHOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIBEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:646-234-3756
Mailing Address - Street 1:1118 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-3317
Mailing Address - Country:US
Mailing Address - Phone:646-234-3756
Mailing Address - Fax:856-210-7488
Practice Address - Street 1:1118 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-3317
Practice Address - Country:US
Practice Address - Phone:646-234-3756
Practice Address - Fax:856-210-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00849400261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1114259850Medicaid