MEDICARE: BALL STATE UNIVERSITY

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	22003456A	IN
2	235Z00000X	Speech-Language Pathologist	22001560	IN
3	235Z00000X	Speech-Language Pathologist	22001905A	IN
4	235Z00000X	Speech-Language Pathologist	22002571	IN
5	235Z00000X	Speech-Language Pathologist	22001890A	IN
6	235Z00000X	Speech-Language Pathologist	22002106	IN
7	235Z00000X	Speech-Language Pathologist	22000224A	IN
8	235Z00000X	Speech-Language Pathologist	22001549	IN
9	235Z00000X	Speech-Language Pathologist	22002004A	IN
10	235Z00000X	Speech-Language Pathologist	22003906A	IN
11	235Z00000X	Speech-Language Pathologist	22002254A	IN
12	231H00000X	Audiologist	23002244A	IN
13	231H00000X	Audiologist	23000144	IN
14	231H00000X	Audiologist	23002284A	IN
15	231H00000X	Audiologist	23002219A	IN

General Provider Information

NPI Number	:	1093937476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALL STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	1613 W RIVERSIDE AVE HB 155
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47306-1022
Country	:	US
Telephone Number	:	765-285-5354
Fax Number	:	765-285-5623

Provider Business Practice Location Address
First Line	:	1613 W RIVERSIDE AVE HB 155
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47306-1022
Country	:	US
Telephone Number	:	765-285-5354
Fax Number	:	765-285-5623

Authorized Official
Title or Position	:	DIR OF CLINICAL OPERATIONS
Name	:	BLAIR SCOTT MATTERN
Credential	:
Telephone Number	:	765-285-5354

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	12/20/2021

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Directions to “BALL STATE UNIVERSITY ” Practice Location

Language	Start Address	Practice Location

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