MEDICARE: JULIE ANNE WEAKLEY KOCH 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	2003004244	MO

General Provider Information

NPI Number	:	1134246002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE ANNE WEAKLEY KOCH CCC-SLP

Provider Business Mailing Address
First Line	:	2541 FAIRLANE DRIVE
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701
Country	:	US
Telephone Number	:	573-334-6343
Fax Number	:

Provider Business Practice Location Address
First Line	:	2541 FAIRLANE DR
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-3616
Country	:	US
Telephone Number	:	573-334-6343
Fax Number	:

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	07/08/2007

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