=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326310582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CBM SPEECH PATHOLOGY SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2012
-----------------------------------------------------
Last Update Date | 02/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10721 CHAPMAN HWY SUITE 22
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37865-4765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-579-2293
-----------------------------------------------------
Fax | 865-579-2295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1223
-----------------------------------------------------
City | SEYMOUR
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37865-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-579-2293
-----------------------------------------------------
Fax | 865-579-2295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. CLAIRE B MOSER
-----------------------------------------------------
Credential | MA, CCC-SLP
-----------------------------------------------------
Telephone | 865-579-2293
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 0000004199
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------