MEDICARE: MRS. JANETTE THANH TAM 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	SP12517	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C1348076	OTHER	CA	DRIVER LICENSE

General Provider Information

NPI Number	:	1619297157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANETTE THANH TAM M.A., CCC- SLP

Provider Business Mailing Address
First Line	:	1064 WATERSIDE DR
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-8152
Country	:	US
Telephone Number	:	801-850-6712
Fax Number	:

Provider Business Practice Location Address
First Line	:	1064 WATERSIDE DR
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-8152
Country	:	US
Telephone Number	:	801-850-6712
Fax Number	:

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

Provider Enumeration Date	:	06/07/2010
Last Update Date	:	06/07/2010

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