MEDICARE: RESTORATIVE SPEECH AND SWALLOW 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	SL-005981-L	PA

General Provider Information

NPI Number	:	1639580517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORATIVE SPEECH AND SWALLOW LLC

Provider Business Mailing Address
First Line	:	220 W EVERGREEN AVE
Second Line	:	UNIT B-1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3862
Country	:	US
Telephone Number	:	215-360-8012
Fax Number	:	866-456-4839

Provider Business Practice Location Address
First Line	:	220 W EVERGREEN AVE
Second Line	:	UNIT B-1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19118-3862
Country	:	US
Telephone Number	:	215-360-8012
Fax Number	:	866-456-4839

Authorized Official
Title or Position	:	OWNER
Name	:	DR. AMY P LUSTIG
Credential	:	PHD, MPH, CCC-SLP
Telephone Number	:	215-360-8012

Provider Enumeration Date	:	05/14/2014
Last Update Date	:	10/26/2015

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Directions to “RESTORATIVE SPEECH AND SWALLOW LLC ” Practice Location

Language	Start Address	Practice Location

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