=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730435983
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTIE L FORD CF-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2012
-----------------------------------------------------
Last Update Date | 07/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10600 LEWIS AND CLARK BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63136-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-430-6389
-----------------------------------------------------
Fax | 866-617-3422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 383
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65355-0383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-438-6993
-----------------------------------------------------
Fax | 866-617-3422
-----------------------------------------------------
=====================================================
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 | 2012025605
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------