MEDICARE: MISS BRITTANY PREVALLET MA, 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	SLP6954	AZ

General Provider Information

NPI Number	:	1295094837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS BRITTANY PREVALLET MA, CCC-SLP

Provider Business Mailing Address
First Line	:	1715 LOS LAGOS DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6648
Country	:	US
Telephone Number	:	573-768-1752
Fax Number	:

Provider Business Practice Location Address
First Line	:	3576 KEARSAGE DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-9115
Country	:	US
Telephone Number	:	928-453-1500
Fax Number	:

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

Provider Enumeration Date	:	05/15/2012
Last Update Date	:	05/15/2012

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