MEDICARE: CELINA RAE FULLER 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	8045244	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12149036	OTHER		ASHA CERTIFICATION

General Provider Information

NPI Number	:	1184902629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CELINA RAE FULLER CCC-SLP

Provider Business Mailing Address
First Line	:	1974 W SHORE RD
Second Line	:
City	:	SALISBURY
State	:	VT
Zip	:	05769-9740
Country	:	US
Telephone Number	:	802-352-4727
Fax Number	:

Provider Business Practice Location Address
First Line	:	1974 W SHORE RD
Second Line	:
City	:	SALISBURY
State	:	VT
Zip	:	05769-9740
Country	:	US
Telephone Number	:	802-352-4727
Fax Number	:

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

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	08/02/2011

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