Provider Demographics
NPI:1902629587
Name:PONTE VEDRA SPEECH THERAPY LLC
Entity type:Organization
Organization Name:PONTE VEDRA SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:904-844-3136
Mailing Address - Street 1:30 TAVERNIER DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0677
Mailing Address - Country:US
Mailing Address - Phone:904-844-3136
Mailing Address - Fax:904-789-6295
Practice Address - Street 1:30 TAVERNIER DR UNIT B
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0677
Practice Address - Country:US
Practice Address - Phone:904-844-3136
Practice Address - Fax:904-789-6295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONTE VEDRA SPEECH LANGUAGE AND LEARNING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty