MEDICARE: BLOOMING SPEECH THERAPY, 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	7138	NC

General Provider Information

NPI Number	:	1336571066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMING SPEECH THERAPY, PLLC

Provider Business Mailing Address
First Line	:	800 SAINT PATRICK ST
Second Line	:
City	:	TARBORO
State	:	NC
Zip	:	27886-3849
Country	:	US
Telephone Number	:	252-904-6047
Fax Number	:	252-563-5864

Provider Business Practice Location Address
First Line	:	800 SAINT PATRICK ST
Second Line	:
City	:	TARBORO
State	:	NC
Zip	:	27886-3849
Country	:	US
Telephone Number	:	252-904-6047
Fax Number	:	252-563-5864

Authorized Official
Title or Position	:	MEMBER/MANAGER/OWNER/SLP
Name	:	COURTNEY H PITT
Credential	:	M.S., CCC-SLP
Telephone Number	:	252-904-6047

Provider Enumeration Date	:	08/05/2013
Last Update Date	:	08/05/2013

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