Basic Information
| Provider Information | |||||||||
| NPI: | 1841621927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COVENANT SPEECH TX PLUS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 ST JOHNS DR | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236664167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577150705 | ||||||||
| FaxNumber: | 7578382582 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 ST JOHNS DR | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236664167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577150705 | ||||||||
| FaxNumber: | 7578382582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2013 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | FLUDD | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | LARRY | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7577150705 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.