MEDICARE: JEAN M HARGRAVE MSCCC 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	SP 4312	OH

General Provider Information

NPI Number	:	1285709337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEAN M HARGRAVE MSCCC SLP

Provider Business Mailing Address
First Line	:	200 WINTER CREEK CT
Second Line	:
City	:	ENGLEWOOD
State	:	OH
Zip	:	45322-2247
Country	:	US
Telephone Number	:	937-836-7223
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 WINTER CREEK CT
Second Line	:
City	:	ENGLEWOOD
State	:	OH
Zip	:	45322-2247
Country	:	US
Telephone Number	:	937-836-7223
Fax Number	:

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

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/25/2008

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