MEDICARE: TERA LABROSCIANO M.A., 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	10604	CA

General Provider Information

NPI Number	:	1306490511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERA LABROSCIANO M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	780 CAPTIVA CIR
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92882-8507
Country	:	US
Telephone Number	:	951-847-5909
Fax Number	:

Provider Business Practice Location Address
First Line	:	30588 VIA LAKISTAS
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-6976
Country	:	US
Telephone Number	:	951-847-5909
Fax Number	:

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

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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