MEDICARE: HAISLUP

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	LIFESTATE	MO

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	:	1518162791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAISLUP

Provider Business Mailing Address
First Line	:	5511 STARLIT DR
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-2245
Country	:	US
Telephone Number	:	314-892-8862
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S GARRISON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2538
Country	:	US
Telephone Number	:	314-340-5902
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	RUTH A FULLER
Credential	:
Telephone Number	:	314-892-8862

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	06/16/2008

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Directions to “HAISLUP ” Practice Location

Language	Start Address	Practice Location

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