Provider Demographics
NPI:1528437621
Name:CREATIVE SPEECH & LANGUAGE THERAPY
Entity type:Organization
Organization Name:CREATIVE SPEECH & LANGUAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:410-841-4514
Mailing Address - Street 1:2104 PINEY BRANCH CIR
Mailing Address - Street 2:#303
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1833
Mailing Address - Country:US
Mailing Address - Phone:410-841-4514
Mailing Address - Fax:
Practice Address - Street 1:2104 PINEY BRANCH CIR
Practice Address - Street 2:#303
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-1833
Practice Address - Country:US
Practice Address - Phone:410-841-4514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07593261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center