=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558762294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH YACKS SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2014
-----------------------------------------------------
Last Update Date | 09/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 E MAIN ST
-----------------------------------------------------
City | AMELIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45102-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-943-3813
-----------------------------------------------------
Fax | 513-943-3642
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 E MAIN ST
-----------------------------------------------------
City | AMELIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45102-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-943-3813
-----------------------------------------------------
Fax | 513-943-3642
-----------------------------------------------------
=====================================================
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 | SP1048
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------