MEDICARE: MISS HOLLEY MARIE BADEN MS 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	SA4103	FL

General Provider Information

NPI Number	:	1104985050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS HOLLEY MARIE BADEN MS CCC SLP

Provider Business Mailing Address
First Line	:	2508 16TH AVE W
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34205-4727
Country	:	US
Telephone Number	:	941-741-8054
Fax Number	:

Provider Business Practice Location Address
First Line	:	3817 E STATE ROAD 64
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34208-9041
Country	:	US
Telephone Number	:	941-745-5111
Fax Number	:	941-745-5667

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

Provider Enumeration Date	:	12/07/2006
Last Update Date	:	07/08/2007

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