MEDICARE: PROFESSIONAL SPEECH SERVICES LLC

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

General Provider Information

NPI Number	:	1518319748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SPEECH SERVICES LLC

Provider Business Mailing Address
First Line	:	1414 TOWERS ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-5447
Country	:	US
Telephone Number	:	908-907-0050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1414 TOWERS ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-5447
Country	:	US
Telephone Number	:	908-907-0050
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	YEHUDIS JUTCOVICH
Credential	:	SLP
Telephone Number	:	908-907-0050

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	07/12/2016

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