Provider Demographics
NPI:1487932760
Name:SOUTHEAST KANSAS SPEECH PATHOLOGY SERVICES, LLC
Entity type:Organization
Organization Name:SOUTHEAST KANSAS SPEECH PATHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GENTRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:620-232-2990
Mailing Address - Street 1:1127 E 570TH AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-8550
Mailing Address - Country:US
Mailing Address - Phone:620-232-2990
Mailing Address - Fax:620-232-2844
Practice Address - Street 1:1800 E 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-8573
Practice Address - Country:US
Practice Address - Phone:620-232-2990
Practice Address - Fax:620-232-2844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty