MEDICARE: MARY LOUISE BONGFELDT 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	12930	TX

General Provider Information

NPI Number	:	1336456813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOUISE BONGFELDT SLP

Provider Business Mailing Address
First Line	:	1533 ATLANTA DR
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-5302
Country	:	US
Telephone Number	:	972-255-6523
Fax Number	:

Provider Business Practice Location Address
First Line	:	1533 ATLANTA DR
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-5302
Country	:	US
Telephone Number	:	72-255-6523
Fax Number	:

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

Provider Enumeration Date	:	09/07/2010
Last Update Date	:	09/07/2010

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Directions to “ MARY LOUISE BONGFELDT SLP” Practice Location

Language	Start Address	Practice Location

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