MEDICARE: DR. LAURA SUE RIDDLE PHD

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	008050	NY

General Provider Information

NPI Number	:	1407819527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA SUE RIDDLE PHD

Provider Business Mailing Address
First Line	:	288 DALE RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14625-2067
Country	:	US
Telephone Number	:	585-249-0209
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 ELMWOOD AVE
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-3042
Country	:	US
Telephone Number	:	585-271-0680
Fax Number	:

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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