Provider Demographics
NPI:1992466098
Name:MIJARES SPEECH LANGUAGE PATHOLOGY, LLC
Entity type:Organization
Organization Name:MIJARES SPEECH LANGUAGE PATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MIJARES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:850-296-7106
Mailing Address - Street 1:3042 CARLOW CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3303
Mailing Address - Country:US
Mailing Address - Phone:850-296-7107
Mailing Address - Fax:850-807-5114
Practice Address - Street 1:3042 CARLOW CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3303
Practice Address - Country:US
Practice Address - Phone:850-296-7106
Practice Address - Fax:850-807-5114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-01
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1962548487Medicaid