MEDICARE: NORTH STAR SPEECH AND LANGUAGE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2202006220	VA

General Provider Information

NPI Number	:	1003105313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH STAR SPEECH AND LANGUAGE, LLC

Provider Business Mailing Address
First Line	:	4301 FOREMAN TRL
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-8015
Country	:	US
Telephone Number	:	757-447-3463
Fax Number	:	757-447-3462

Provider Business Practice Location Address
First Line	:	4301 FOREMAN TRL
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-8015
Country	:	US
Telephone Number	:	757-447-3463
Fax Number	:	757-447-3462

Authorized Official
Title or Position	:	OWNER, SPEECH-LANGUAGE PATHOLOGIST
Name	:	LAURA LOVELESS
Credential	:	M.S. CCC-SLP
Telephone Number	:	757-447-3463

Provider Enumeration Date	:	04/07/2011
Last Update Date	:	04/07/2011

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