MEDICARE: BRYLIE SOUTH 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.16234	OH

General Provider Information

NPI Number	:	1205790029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYLIE SOUTH CCC-SLP

Provider Business Mailing Address
First Line	:	5935 WOODSPOINT DR
Second Line	:
City	:	MILFORD
State	:	OH
Zip	:	45150-2186
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5225 COX SMITH RD
Second Line	:
City	:	MASON
State	:	OH
Zip	:	45040-9276
Country	:	US
Telephone Number	:	513-549-2930
Fax Number	:

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

Provider Enumeration Date	:	12/15/2025
Last Update Date	:	12/15/2025

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Directions to “ BRYLIE SOUTH CCC-SLP” Practice Location

Language	Start Address	Practice Location

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