MEDICARE: MRS. BETHANY JOY DWYER MS/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	2007540	IL

General Provider Information

NPI Number	:	1821516998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BETHANY JOY DWYER MS/CCC-SLP

Provider Business Mailing Address
First Line	:	10911 PAULTON RD
Second Line	:
City	:	PITTSBURG
State	:	IL
Zip	:	62974-1706
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4877 STATE HIGHWAY 148
Second Line	:
City	:	MULKEYTOWN
State	:	IL
Zip	:	62865-3295
Country	:	US
Telephone Number	:	618-596-2121
Fax Number	:

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

Provider Enumeration Date	:	09/08/2017
Last Update Date	:	03/17/2018

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