MEDICARE: MRS. MICHELLE DENISE MATOLKA MS, CCC/L-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	SA13884	FL

General Provider Information

NPI Number	:	1093950826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE DENISE MATOLKA MS, CCC/L-SLP

Provider Business Mailing Address
First Line	:	1809 E BROADWAY ST
Second Line	:	# 122
City	:	OVIEDO
State	:	FL
Zip	:	32765-8597
Country	:	US
Telephone Number	:	407-359-5693
Fax Number	:	407-792-5693

Provider Business Practice Location Address
First Line	:	1809 E BROADWAY ST # 122
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765-8597
Country	:	US
Telephone Number	:	407-359-5693
Fax Number	:

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

Provider Enumeration Date	:	12/08/2008
Last Update Date	:	01/21/2016

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