MEDICARE: MR. VINCENT PEDERSON 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		IL

General Provider Information

NPI Number	:	1174677413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VINCENT PEDERSON CCC-SLP

Provider Business Mailing Address
First Line	:	18483 W GEIER RD
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-1305
Country	:	US
Telephone Number	:	224-643-7713
Fax Number	:

Provider Business Practice Location Address
First Line	:	1442 OLD SKOKIE RD
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-3032
Country	:	US
Telephone Number	:	847-486-4140
Fax Number	:

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. VINCENT PEDERSON CCC-SLP” Practice Location

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