MEDICARE: MARINA TAWADROUS MINA 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	14146770	FL
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1285016121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA TAWADROUS MINA CCC-SLP

Provider Business Mailing Address
First Line	:	465 S ORLANDO AVE STE 320
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-5654
Country	:	US
Telephone Number	:	407-790-5601
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 WESTWOOD SQ STE D
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765-8849
Country	:	US
Telephone Number	:	407-790-5601
Fax Number	:

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

Provider Enumeration Date	:	06/27/2015
Last Update Date	:	03/27/2018

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