MEDICARE: JOY R FAVOR MCD 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	4400	LA

General Provider Information

NPI Number	:	1194053926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOY R FAVOR MCD CCC-SLP

Provider Business Mailing Address
First Line	:	2112 OCTAVIA ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70115-5656
Country	:	US
Telephone Number	:	205-447-1260
Fax Number	:

Provider Business Practice Location Address
First Line	:	2112 OCTAVIA ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70115-5656
Country	:	US
Telephone Number	:	205-447-1260
Fax Number	:

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

Provider Enumeration Date	:	12/07/2009
Last Update Date	:	12/07/2009

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