MEDICARE: MRS. REBECCA L FORD

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	22000966A	IN

General Provider Information

NPI Number	:	1063639052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA L FORD

Provider Business Mailing Address
First Line	:	10806 E ROSEWOOD CIR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1144
Country	:	US
Telephone Number	:	260-402-3359
Fax Number	:	260-637-9945

Provider Business Practice Location Address
First Line	:	10806 E ROSEWOOD CIR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1144
Country	:	US
Telephone Number	:	260-402-3359
Fax Number	:	260-637-9945

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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Directions to “ MRS. REBECCA L FORD ” Practice Location

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