MEDICARE: SHERIDAN BROOKE KALUZNIAK CCC-SLP

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	119667	TX

General Provider Information

NPI Number	:	1023725918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERIDAN BROOKE KALUZNIAK CCC-SLP

Provider Business Mailing Address
First Line	:	5300 BUCHANAN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1304
Country	:	US
Telephone Number	:	817-252-2521
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 BUCHANAN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-1304
Country	:	US
Telephone Number	:	817-252-2521
Fax Number	:

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

Provider Enumeration Date	:	11/01/2022
Last Update Date	:	11/01/2022

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Directions to “ SHERIDAN BROOKE KALUZNIAK CCC-SLP” Practice Location

Language	Start Address	Practice Location

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