MEDICARE: TERRELL SUBLETT

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	SA6422	FL

General Provider Information

NPI Number	:	1134490592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRELL SUBLETT

Provider Business Mailing Address
First Line	:	1512 JASPER AVE NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-8619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 JASPER AVE NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-8619
Country	:	US
Telephone Number	:	321-728-0090
Fax Number	:

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

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/17/2012

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Directions to “ TERRELL SUBLETT ” Practice Location

Language	Start Address	Practice Location

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