MEDICARE: JOYCE VIDELOCK

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	SL002481L	PA

General Provider Information

NPI Number	:	1366704421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOYCE VIDELOCK

Provider Business Mailing Address
First Line	:	3026 MIDVALE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1028
Country	:	US
Telephone Number	:	215-219-6327
Fax Number	:

Provider Business Practice Location Address
First Line	:	3026 MIDVALE AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1028
Country	:	US
Telephone Number	:	215-219-6327
Fax Number	:

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/13/2012

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Directions to “ JOYCE VIDELOCK ” Practice Location

Language	Start Address	Practice Location

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