Provider Demographics
NPI:1447691910
Name:LILY PEARL SPEECH THERAPY, LLC
Entity type:Organization
Organization Name:LILY PEARL SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNAH
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:EDGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:812-322-0052
Mailing Address - Street 1:824 W. 4TH ST.
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404
Mailing Address - Country:US
Mailing Address - Phone:812-322-0052
Mailing Address - Fax:
Practice Address - Street 1:824 W 4TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-5012
Practice Address - Country:US
Practice Address - Phone:812-322-0052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005087A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty