MEDICARE: LAURA MCCALLUM

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	SLP007293	GA

General Provider Information

NPI Number	:	1962964601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA MCCALLUM

Provider Business Mailing Address
First Line	:	7527 MOSSY LOG CT
Second Line	:
City	:	FLOWERY BRANCH
State	:	GA
Zip	:	30542-7713
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 OLD HAMILTON PL
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30507-7892
Country	:	US
Telephone Number	:	770-532-2066
Fax Number	:

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

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	04/02/2019

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Directions to “ LAURA MCCALLUM ” Practice Location

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