MEDICARE: MRS. JUSTINE TAYLOR THEISEN M.A. 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	SA10918	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

General Provider Information

NPI Number	:	1598056707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUSTINE TAYLOR THEISEN M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	5811 BAMBOO DRIVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-3758
Country	:	US
Telephone Number	:	772-242-3187
Fax Number	:	772-494-7262

Provider Business Practice Location Address
First Line	:	5811 BAMBOO DRIVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-3758
Country	:	US
Telephone Number	:	772-242-3187
Fax Number	:	772-494-7262

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

Provider Enumeration Date	:	04/21/2011
Last Update Date	:	08/30/2016

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