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General NPI Number Information
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NPI Number | 1164080974
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Entity Type | Organization
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Legal Business Name | MIDWEST MYOFUNCTIONAL AND SPEECH THERAPY, LLC
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Dates
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Enumeration Date | 06/05/2019
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Last Update Date | 06/05/2019
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Provider Practice Location Address
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Address Line | 7221 ENGLE RD STE 225
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City | FORT WAYNE
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State | IN
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Zip | 46804-2229
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Country | US
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Telephone | 260-438-1430
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Fax |
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Provider Business Mailing Address
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Address Line | 10909 W SYCAMORE HILLS DR
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City | FORT WAYNE
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State | IN
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Zip | 46814-9335
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Country | US
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Telephone | 260-438-1430
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Fax |
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Authorized Official
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Title or Position | SPEECH-LANGUAGE PATHOLOGIST
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Name | JULIE A CARRICO
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Credential | SLP
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Telephone | 260-438-1430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number |
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License Number State |
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