Provider Demographics
NPI:1992142392
Name:KING, JANELLE SURI (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:SURI
Last Name:KING
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 ANDREW DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1104
Mailing Address - Country:US
Mailing Address - Phone:850-461-3352
Mailing Address - Fax:
Practice Address - Street 1:4624 SUMMERDALE DR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1368
Practice Address - Country:US
Practice Address - Phone:850-994-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-27
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist