MEDICARE: MADELINE INCE MS 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	2019018004	MO

General Provider Information

NPI Number	:	1154089985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE INCE MS CCC-SLP

Provider Business Mailing Address
First Line	:	3800 PARK AVE FL 2
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2514
Country	:	US
Telephone Number	:	314-678-6648
Fax Number	:	314-268-4028

Provider Business Practice Location Address
First Line	:	3800 PARK AVE FL 2
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63110-2514
Country	:	US
Telephone Number	:	314-678-6648
Fax Number	:	314-268-4028

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

Provider Enumeration Date	:	11/29/2021
Last Update Date	:	11/29/2021

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