MEDICARE: THE SPEECH PATHOLOGY CENTER OF LOUISIANA, LLC

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	2002	LA

General Provider Information

NPI Number	:	1164591038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SPEECH PATHOLOGY CENTER OF LOUISIANA, LLC

Provider Business Mailing Address
First Line	:	8676 GOODWOOD BLVD
Second Line	:	SUITE 204
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-7914
Country	:	US
Telephone Number	:	225-923-1140
Fax Number	:	225-923-1326

Provider Business Practice Location Address
First Line	:	8676 GOODWOOD BLVD
Second Line	:	SUITE 204
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-7914
Country	:	US
Telephone Number	:	225-923-1140
Fax Number	:	225-923-1326

Authorized Official
Title or Position	:	MEMBER
Name	:	MS. MONDRA ROSE FAZELY
Credential	:	CCC
Telephone Number	:	225-923-1140

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/22/2020

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