MEDICARE: KSENIJA MASTILOVIC

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	146008436	IL

General Provider Information

NPI Number	:	1134392707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KSENIJA MASTILOVIC

Provider Business Mailing Address
First Line	:	5645 N COURTLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2907
Country	:	US
Telephone Number	:	847-987-0343
Fax Number	:

Provider Business Practice Location Address
First Line	:	5645 N COURTLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-2907
Country	:	US
Telephone Number	:	847-987-0343
Fax Number	:

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

Provider Enumeration Date	:	04/03/2008
Last Update Date	:	10/14/2009

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Directions to “ KSENIJA MASTILOVIC ” Practice Location

Language	Start Address	Practice Location

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