=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174183347
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEVERLY LORD M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2019
-----------------------------------------------------
Last Update Date | 04/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 S DILLARD ST STE 106
-----------------------------------------------------
City | WINTER GARDEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34787-3991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-877-0029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 WITHERS CT
-----------------------------------------------------
City | OCOEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34761-1438
-----------------------------------------------------
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 | SA17994
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------