MEDICARE: MARNI B SIMON MA, CCC-SLP, BCS-S

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	SA15801	FL
2	222Q00000X	Developmental Therapist	SA15801	FL

General Provider Information

NPI Number	:	1184119299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARNI B SIMON MA, CCC-SLP, BCS-S

Provider Business Mailing Address
First Line	:	565 ACACIA AVE
Second Line	:
City	:	MELBOURNE VILLAGE
State	:	FL
Zip	:	32904-2501
Country	:	US
Telephone Number	:	850-857-9343
Fax Number	:	844-848-7557

Provider Business Practice Location Address
First Line	:	565 ACACIA AVE
Second Line	:
City	:	MELBOURNE VILLAGE
State	:	FL
Zip	:	32904
Country	:	US
Telephone Number	:	850-857-9343
Fax Number	:	844-848-7557

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

Provider Enumeration Date	:	06/30/2018
Last Update Date	:	03/17/2019

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