MEDICARE: PHENOM SPEECH THERAPY, LLC

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-1264	NV

General Provider Information

NPI Number	:	1265727598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHENOM SPEECH THERAPY, LLC

Provider Business Mailing Address
First Line	:	9850 S MARYLAND PKWY
Second Line	:	STE A-5 #264
City	:	LAS VEGAS
State	:	NV
Zip	:	89183-7146
Country	:	US
Telephone Number	:	702-985-8385
Fax Number	:

Provider Business Practice Location Address
First Line	:	9937 DELICATE DEW ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89183-7153
Country	:	US
Telephone Number	:	702-985-8385
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	CORRIE RILLING
Credential	:	M.S., CCC-SLP
Telephone Number	:	208-919-4189

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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Directions to “PHENOM SPEECH THERAPY, LLC ” Practice Location

Language	Start Address	Practice Location

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