MEDICARE: AUTUMN HEINSELMAN MA, 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	106131	TX
2	235Z00000X	Speech-Language Pathologist	4547	SC
3	235Z00000X	Speech-Language Pathologist	9097	NC
4	314000000X	Skilled Nursing Facility	106131	TX

General Provider Information

NPI Number	:	1336433986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN HEINSELMAN MA, CCC-SLP

Provider Business Mailing Address
First Line	:	7025 REED CT
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7950
Country	:	US
Telephone Number	:	904-662-0563
Fax Number	:

Provider Business Practice Location Address
First Line	:	5437 EISENHAUER RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-3757
Country	:	US
Telephone Number	:	210-646-9576
Fax Number	:

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

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	05/31/2011

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