Provider Demographics
NPI:1871909432
Name:EASTERN KENTUCKY SPEECH AND LANGUAGE CLINIC
Entity type:Organization
Organization Name:EASTERN KENTUCKY SPEECH AND LANGUAGE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:606-205-3121
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41666-0183
Mailing Address - Country:US
Mailing Address - Phone:606-205-3121
Mailing Address - Fax:606-447-2493
Practice Address - Street 1:3041 KY RT 7
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:KY
Practice Address - Zip Code:41666
Practice Address - Country:US
Practice Address - Phone:606-205-3121
Practice Address - Fax:606-447-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2895235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100280630Medicaid