=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023535408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSALIE MAUL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2017
-----------------------------------------------------
Last Update Date | 08/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 W 3RD ST
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-2044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-632-6327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1779 BENTWATER LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-6325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-580-1945
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146.005560
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------