=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922816123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAYLOR ROGGENBAUM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 LANGMAID LN
-----------------------------------------------------
City | BRADFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16701-3930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-804-9961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8477 S SUNCOAST BLVD
-----------------------------------------------------
City | HOMOSASSA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34446-5028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-381-0822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235500000X
-----------------------------------------------------
Taxonomy Name | Speech/Language/Hearing Specialist/Technologist
-----------------------------------------------------
License Number | SL016878
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------