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General NPI Number Information
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NPI Number | 1104058866
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Entity Type | Organization
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Legal Business Name | GENESIS REHAB
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Dates
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Enumeration Date | 08/13/2009
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Last Update Date | 08/13/2009
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Provider Practice Location Address
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Address Line | 2626 GOODLETTE RD N
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City | NAPLES
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State | FL
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Zip | 34103-4526
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Country | US
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Telephone | 239-262-3814
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Fax | 239-262-5687
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Provider Business Mailing Address
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Address Line | 74 RIDGE DR
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City | NAPLES
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State | FL
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Zip | 34108-3440
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Country | US
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Telephone | 239-254-1020
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Fax | 239-597-5289
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Authorized Official
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Title or Position | SPEECH-LANGUAGE PATHOLOGIST
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Name | MRS. STACY CHERYL BRAVERMAN
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Credential | CCC-SLP
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Telephone | 239-282-3814
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | SA6013
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License Number State | FL
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