MEDICARE: NICOLE MARX MHS CCC SLP/L

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	146.010636	IL

General Provider Information

NPI Number	:	1932492360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARX MHS CCC SLP/L

Provider Business Mailing Address
First Line	:	2145 W 95TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1018
Country	:	US
Telephone Number	:	773-233-7855
Fax Number	:

Provider Business Practice Location Address
First Line	:	2145 W 95TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1018
Country	:	US
Telephone Number	:	773-233-7855
Fax Number	:	773-233-7858

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

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	05/18/2011

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