MEDICARE: JUSTIN EDWARD BACON

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	:	1144101452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN EDWARD BACON

Provider Business Mailing Address
First Line	:	3776 W 137TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-4441
Country	:	US
Telephone Number	:	440-665-5390
Fax Number	:

Provider Business Practice Location Address
First Line	:	42331 GRISWOLD RD
Second Line	:
City	:	ELYRIA
State	:	OH
Zip	:	44035-2121
Country	:	US
Telephone Number	:	440-284-8250
Fax Number	:

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

Provider Enumeration Date	:	09/11/2025
Last Update Date	:	09/11/2025

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Directions to “ JUSTIN EDWARD BACON ” Practice Location

Language	Start Address	Practice Location

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