MEDICARE: KIRSTEN ELISE MULL M.A., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146.010949	IL

General Provider Information

NPI Number	:	1093084386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN ELISE MULL M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	656 E 51ST ST APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-3609
Country	:	US
Telephone Number	:	812-267-5030
Fax Number	:

Provider Business Practice Location Address
First Line	:	656 E 51ST ST APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-3609
Country	:	US
Telephone Number	:	812-267-5030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2011
Last Update Date	:	12/15/2011

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