MEDICARE: MS. DIANE EVANS - BLAKE 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	1990	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356547616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE EVANS - BLAKE SLP

Provider Business Mailing Address
First Line	:	3307 CROSS WINDS RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-6613
Country	:	US
Telephone Number	:	704-668-3549
Fax Number	:

Provider Business Practice Location Address
First Line	:	3307 CROSS WINDS RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-6613
Country	:	US
Telephone Number	:	704-668-3549
Fax Number	:

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/09/2007

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