Provider Demographics
NPI:1831235712
Name:BACHELLER, LONDON M
Entity type:Individual
Prefix:
First Name:LONDON
Middle Name:M
Last Name:BACHELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LONDON
Other - Middle Name:M
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSCCC-SLP
Mailing Address - Street 1:PO BOX 27906
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32411
Mailing Address - Country:US
Mailing Address - Phone:850-598-5522
Mailing Address - Fax:
Practice Address - Street 1:3203 PRESERVE TRAILS BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32408-7132
Practice Address - Country:US
Practice Address - Phone:850-598-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8846383000Medicaid
12025639OtherASHA