MEDICARE: MST KIDS 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	SA11674	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326582313
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MST KIDS LLC

Provider Business Mailing Address
First Line	:	12030 SW 123RD TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-5156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12030 SW 123RD TER
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-5156
Country	:	US
Telephone Number	:	305-283-5884
Fax Number	:

Authorized Official
Title or Position	:	SPEECH PATHOLOGIST
Name	:	MARCELLA GALLEGO
Credential	:
Telephone Number	:	305-283-5884

Provider Enumeration Date	:	12/09/2016
Last Update Date	:	12/09/2016

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Directions to “MST KIDS LLC ” Practice Location

Language	Start Address	Practice Location

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