MEDICARE: MY THERAPY SPOT 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
2	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013635358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY THERAPY SPOT LLC

Provider Business Mailing Address
First Line	:	18822 NW 80TH CT
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-5228
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18822 NW 80TH CT
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-5228
Country	:	US
Telephone Number	:	305-440-0785
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	JENNIFER TRAVIESO
Credential	:	SLP
Telephone Number	:	305-440-0785

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	08/22/2022

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Directions to “MY THERAPY SPOT LLC ” Practice Location

Language	Start Address	Practice Location

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