Provider Demographics
NPI:1447526991
Name:PEDIATRIC SPEECH AND LANGUAGE CENTER
Entity type:Organization
Organization Name:PEDIATRIC SPEECH AND LANGUAGE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VANWINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-377-2523
Mailing Address - Street 1:6825 SILVER PONDS HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-4774
Mailing Address - Country:US
Mailing Address - Phone:719-377-2523
Mailing Address - Fax:719-355-8452
Practice Address - Street 1:6825 SILVER PONDS HTS
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80908-4774
Practice Address - Country:US
Practice Address - Phone:719-377-2523
Practice Address - Fax:719-355-8452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12140923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86072579Medicaid