MEDICARE: MRS. SARAJANE MANLY BROGNANO 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

General Provider Information

NPI Number	:	1114293685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARAJANE MANLY BROGNANO CCC-SLP

Provider Business Mailing Address
First Line	:	PO BOX 85
Second Line	:
City	:	SOUTH WALES
State	:	NY
Zip	:	14139-0085
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2491 EMERY RD
Second Line	:
City	:	SOUTH WALES
State	:	NY
Zip	:	14139-9408
Country	:	US
Telephone Number	:	222-222-2222
Fax Number	:

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

Provider Enumeration Date	:	03/28/2012
Last Update Date	:	07/15/2015

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