MEDICARE: PAIGE MACK M.A. 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	SP.13466	OH

General Provider Information

NPI Number	:	1174017974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAIGE MACK M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	11907 W COUNTY ROAD 10
Second Line	:
City	:	ALVADA
State	:	OH
Zip	:	44802-9701
Country	:	US
Telephone Number	:	419-619-5094
Fax Number	:

Provider Business Practice Location Address
First Line	:	27 ST LAWRENCE DR STE 104
Second Line	:
City	:	TIFFIN
State	:	OH
Zip	:	44883-8313
Country	:	US
Telephone Number	:	419-455-7900
Fax Number	:

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

Provider Enumeration Date	:	06/15/2018
Last Update Date	:	05/19/2020

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