MEDICARE: MS. ELVA A ROSS 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	2004014099	MO
2	235Z00000X	Speech-Language Pathologist		IL

General Provider Information

NPI Number	:	1073547881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELVA A ROSS CCC SLP

Provider Business Mailing Address
First Line	:	PO BOX 18751
Second Line	:
City	:	ST LOUIS
State	:	MO
Zip	:	63118
Country	:	US
Telephone Number	:	314-773-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 MICHIGAN AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-3610
Country	:	US
Telephone Number	:	314-773-6770
Fax Number	:

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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