MEDICARE: MRS. REBECCA BANE SOUTHERN MA/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	1829	NC

General Provider Information

NPI Number	:	1558200436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA BANE SOUTHERN MA/CCC-SLP

Provider Business Mailing Address
First Line	:	PO BOX 624
Second Line	:
City	:	LEWISVILLE
State	:	NC
Zip	:	27023-0624
Country	:	US
Telephone Number	:	336-817-6789
Fax Number	:

Provider Business Practice Location Address
First Line	:	3785 FRATERNITY CHURCH RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-8723
Country	:	US
Telephone Number	:	336-817-6789
Fax Number	:

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

Provider Enumeration Date	:	03/26/2026
Last Update Date	:	03/26/2026

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Directions to “ MRS. REBECCA BANE SOUTHERN MA/CCC-SLP” Practice Location

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