Provider Demographics
NPI:1447631346
Name:SPEECH AT THE BEACH, PLLC
Entity type:Organization
Organization Name:SPEECH AT THE BEACH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:KROUSE
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:252-241-6955
Mailing Address - Street 1:207 CEDAR KEY WAY
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28570-5566
Mailing Address - Country:US
Mailing Address - Phone:252-241-6955
Mailing Address - Fax:252-764-2461
Practice Address - Street 1:207 CEDAR KEY WAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NC
Practice Address - Zip Code:28570-5566
Practice Address - Country:US
Practice Address - Phone:252-241-6955
Practice Address - Fax:252-764-2461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1811313315Medicaid