MEDICARE: MRS. JODI L GOGOS MSCCCSLP

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	22002999A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	870763354	OTHER	IN	TAX ID

General Provider Information

NPI Number	:	1548369333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JODI L GOGOS MSCCCSLP

Provider Business Mailing Address
First Line	:	10315 DAWSONS CREEK BLVD
Second Line	:	STE I
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1914
Country	:	US
Telephone Number	:	260-450-3617
Fax Number	:	260-436-4946

Provider Business Practice Location Address
First Line	:	10315 DAWSONS CREEK BLVD
Second Line	:	STE I
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1914
Country	:	US
Telephone Number	:	260-450-3617
Fax Number	:	260-436-4946

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	11/04/2010

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Directions to “ MRS. JODI L GOGOS MSCCCSLP” Practice Location

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