MEDICARE: FUNDAMENTAL SPEECH THERAPY

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

General Provider Information

NPI Number	:	1083342620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNDAMENTAL SPEECH THERAPY

Provider Business Mailing Address
First Line	:	6688 NOLESVILLE ROAD
Second Line	:	STE 108-133
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-8833
Country	:	US
Telephone Number	:	615-348-9991
Fax Number	:	615-616-8725

Provider Business Practice Location Address
First Line	:	7049 SUNNYWOOD DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37211-8624
Country	:	US
Telephone Number	:	305-788-1739
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	MELISSA OLIVA
Credential	:	MS, CCC-SLP
Telephone Number	:	305-788-1739

Provider Enumeration Date	:	08/11/2022
Last Update Date	:	06/26/2023

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Directions to “FUNDAMENTAL SPEECH THERAPY ” Practice Location

Language	Start Address	Practice Location

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