Provider Demographics
NPI:1962080630
Name:INNOVATIVE MEDICAL SPEECH LANGUAGE PATHOLOGY AND REHAB SERVICES, INC.
Entity type:Organization
Organization Name:INNOVATIVE MEDICAL SPEECH LANGUAGE PATHOLOGY AND REHAB SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR AND LEAD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:SHELBY
Authorized Official - Suffix:
Authorized Official - Credentials:MCD CCCSLP
Authorized Official - Phone:501-291-7222
Mailing Address - Street 1:105 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72417-8831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 N OAK ST
Practice Address - Street 2:
Practice Address - City:BROOKLAND
Practice Address - State:AR
Practice Address - Zip Code:72417-8831
Practice Address - Country:US
Practice Address - Phone:870-497-0326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-01
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty