MEDICARE: TAMARA R FOURTH M.S, 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	SA17846	FL

General Provider Information

NPI Number	:	1356974190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA R FOURTH M.S, CCC-SLP

Provider Business Mailing Address
First Line	:	3020 MESA VERDE DR APT 1906
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-4369
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 MESA VERDE DR APT 1906
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32837-4369
Country	:	US
Telephone Number	:	407-435-0191
Fax Number	:

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

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	05/12/2020

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Directions to “ TAMARA R FOURTH M.S, CCC-SLP” Practice Location

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