MEDICARE: SPEECH LANGUAGE FUNDAMENTALS INC

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	146007330	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001633463	OTHER		BCBS

General Provider Information

NPI Number	:	1255408746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPEECH LANGUAGE FUNDAMENTALS INC

Provider Business Mailing Address
First Line	:	2923 198TH PL
Second Line	:
City	:	LYNWOOD
State	:	IL
Zip	:	60411-4546
Country	:	US
Telephone Number	:	708-299-4799
Fax Number	:	708-849-6079

Provider Business Practice Location Address
First Line	:	2923 198TH PL
Second Line	:
City	:	LYNWOOD
State	:	IL
Zip	:	60411-4546
Country	:	US
Telephone Number	:	708-299-4799
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF SERVICES/OWNER
Name	:	MRS. LINDA MARIE GOFORTH
Credential	:	MHS CCC-SLP/L
Telephone Number	:	708-299-4799

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/27/2009

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Directions to “SPEECH LANGUAGE FUNDAMENTALS INC ” Practice Location

Language	Start Address	Practice Location

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