MEDICARE: SEASTAR SPEECH THERAPY LLC

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	261QH0700X	Hearing and Speech Clinic/Center	01129463	CO

General Provider Information

NPI Number	:	1134414345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEASTAR SPEECH THERAPY LLC

Provider Business Mailing Address
First Line	:	1255 LAKE PLAZA DR
Second Line	:	SUITE269
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3500
Country	:	US
Telephone Number	:	719-538-6027
Fax Number	:	719-344-2328

Provider Business Practice Location Address
First Line	:	1255 LAKE PLAZA DR
Second Line	:	SUITE269
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-3500
Country	:	US
Telephone Number	:	719-538-6027
Fax Number	:	719-344-2328

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MRS. TAMARA ANN GORMAN
Credential	:	MS, CCC-SLP
Telephone Number	:	719-538-6027

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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