MEDICARE: MS. LUCILLE IDAROLA 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	SA6006	FL

General Provider Information

NPI Number	:	1215123260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LUCILLE IDAROLA CCC-SLP

Provider Business Mailing Address
First Line	:	2495 SW CENTERVILLE AVE
Second Line	:
City	:	FORT WHITE
State	:	FL
Zip	:	32038-6110
Country	:	US
Telephone Number	:	352-339-5753
Fax Number	:

Provider Business Practice Location Address
First Line	:	2495 SW CENTERVILLE AVE
Second Line	:
City	:	FORT WHITE
State	:	FL
Zip	:	32038-6110
Country	:	US
Telephone Number	:	352-339-5753
Fax Number	:

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

Provider Enumeration Date	:	09/23/2007
Last Update Date	:	09/23/2007

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