MEDICARE: KELLY COOPER-BISTRICKY MS 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	SP18316	CA

General Provider Information

NPI Number	:	1053619767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY COOPER-BISTRICKY MS CCC SLP

Provider Business Mailing Address
First Line	:	2528 OCEAN AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94132-1614
Country	:	US
Telephone Number	:	415-469-4988
Fax Number	:	646-758-5802

Provider Business Practice Location Address
First Line	:	2528 OCEAN AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94132-1614
Country	:	US
Telephone Number	:	415-469-4988
Fax Number	:	646-758-5802

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

Provider Enumeration Date	:	03/03/2011
Last Update Date	:	03/03/2011

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