MEDICARE: MS. MANDY MARIE SINE MED 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	SLP006879	GA

General Provider Information

NPI Number	:	1184863367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MANDY MARIE SINE MED CCC-SLP

Provider Business Mailing Address
First Line	:	2620 N BERKELEY LAKE RD NW
Second Line	:	APT 535
City	:	DULUTH
State	:	GA
Zip	:	30096-1448
Country	:	US
Telephone Number	:	678-362-1774
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 N BERKELEY LAKE RD NW
Second Line	:	APT 535
City	:	DULUTH
State	:	GA
Zip	:	30096-1448
Country	:	US
Telephone Number	:	678-362-1774
Fax Number	:

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

Provider Enumeration Date	:	02/12/2009
Last Update Date	:	02/12/2009

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