MEDICARE: SOAR SPEECH THERAPY AND CONSULTING, PLLC

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	9913	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9913	OTHER	NC	NC BOARD OF EXAMINERS FOR SPEECH AND LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS

General Provider Information

NPI Number	:	1235502519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOAR SPEECH THERAPY AND CONSULTING, PLLC

Provider Business Mailing Address
First Line	:	521 KING EDWARD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4627
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 KING EDWARD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4627
Country	:	US
Telephone Number	:	858-354-0453
Fax Number	:

Authorized Official
Title or Position	:	SPEECH-LANGUAGE PATHOLOGIST
Name	:	COLLEEN MARIE NOLAN
Credential	:	M.S. CCC-SLP
Telephone Number	:	858-354-0453

Provider Enumeration Date	:	11/09/2015
Last Update Date	:	11/16/2015

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