=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063238384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER LORETTA SALUTRIC M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2024
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9307 BRIDGEPORT WAY SW
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98499-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-201-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16536 W LANFEAR DR
-----------------------------------------------------
City | LOCKPORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60441-4742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 61547962
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------