MEDICARE: LAURA POLIQUIN BADERTSCHER 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	SA 4559	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407878390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA POLIQUIN BADERTSCHER CCC/SLP

Provider Business Mailing Address
First Line	:	2228 GOLF MANOR BLVD
Second Line	:
City	:	VALRICO
State	:	FL
Zip	:	33594-7850
Country	:	US
Telephone Number	:	813-423-0400
Fax Number	:

Provider Business Practice Location Address
First Line	:	10817 BLOOMINGDALE AVE
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33578-3616
Country	:	US
Telephone Number	:	813-643-3144
Fax Number	:

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

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	10/19/2011

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