MEDICARE: MODENA JEAN MOLEN MA 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	1999138148	MO

General Provider Information

NPI Number	:	1033367958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MODENA JEAN MOLEN MA CCC SLP

Provider Business Mailing Address
First Line	:	11960 WESTLINE INDUSTRIAL DR
Second Line	:	SUITE #201
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11960 WESTLINE INDUSTRIAL DR
Second Line	:	SUITE #201
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3209
Country	:	US
Telephone Number	:	314-819-0480
Fax Number	:

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

Provider Enumeration Date	:	09/04/2008
Last Update Date	:	09/04/2008

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