=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912483140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY TERESA MOSHURE M.A. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2018
-----------------------------------------------------
Last Update Date | 07/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1006 N MILLS AVE
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34266-8811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-494-8450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2837 TISHMAN AVE
-----------------------------------------------------
City | NORTH PORT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34286-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-257-2031
-----------------------------------------------------
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 | SA16198
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------