Provider Demographics
NPI:1538861802
Name:PEDIATRIC SPEECH LAB
Entity type:Organization
Organization Name:PEDIATRIC SPEECH LAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:QUINTINA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-355-3839
Mailing Address - Street 1:11350 PEMBROOKE SQ STE 313
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4809
Mailing Address - Country:US
Mailing Address - Phone:202-355-3839
Mailing Address - Fax:
Practice Address - Street 1:11350 PEMBROOKE SQ STE 313
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4809
Practice Address - Country:US
Practice Address - Phone:202-355-3839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service