Provider Demographics
NPI:1366901985
Name:VINE SPEECH PATHOLOGY, CORP.
Entity type:Organization
Organization Name:VINE SPEECH PATHOLOGY, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-620-4346
Mailing Address - Street 1:134 BEEHLER RD
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-7663
Mailing Address - Country:US
Mailing Address - Phone:347-310-5985
Mailing Address - Fax:570-620-4342
Practice Address - Street 1:246 STADDEN RD STE 103
Practice Address - Street 2:
Practice Address - City:TANNERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18372-7944
Practice Address - Country:US
Practice Address - Phone:570-620-4346
Practice Address - Fax:570-620-4342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035895390002Medicaid