MEDICARE: REGINA CAROL FORD MACCCSLP

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	0338	WV

General Provider Information

NPI Number	:	1013032358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA CAROL FORD MACCCSLP

Provider Business Mailing Address
First Line	:	2 HIDDEN CV
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1172
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 LINCOLN DR
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-2304
Country	:	US
Telephone Number	:	304-768-4400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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