Provider Demographics
NPI:1871914002
Name:MID IOWA SPEECH THERAPY
Entity type:Organization
Organization Name:MID IOWA SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC SLP
Authorized Official - Phone:515-314-3800
Mailing Address - Street 1:6850 CERES CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1657
Mailing Address - Country:US
Mailing Address - Phone:515-314-3800
Mailing Address - Fax:515-270-9376
Practice Address - Street 1:6850 CERES CIR
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1657
Practice Address - Country:US
Practice Address - Phone:515-314-3800
Practice Address - Fax:515-270-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA471235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty