MEDICARE: ABIGAIL JAN WIRTH MA, 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	0913	NH

General Provider Information

NPI Number	:	1952744047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL JAN WIRTH MA, CCC-SLP

Provider Business Mailing Address
First Line	:	55 DARGIE LN
Second Line	:
City	:	EAST RYEGATE
State	:	VT
Zip	:	05042-8970
Country	:	US
Telephone Number	:	802-757-3469
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 DARGIE LN
Second Line	:
City	:	EAST RYEGATE
State	:	VT
Zip	:	05042-8970
Country	:	US
Telephone Number	:	802-757-3469
Fax Number	:

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

Provider Enumeration Date	:	04/09/2013
Last Update Date	:	04/09/2013

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