MEDICARE: PROACTIVE PEDIATRICS, 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

General Provider Information

NPI Number	:	1346639507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE PEDIATRICS, LLC

Provider Business Mailing Address
First Line	:	1143 IVY ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-4542
Country	:	US
Telephone Number	:	720-318-4615
Fax Number	:

Provider Business Practice Location Address
First Line	:	1143 IVY ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-4542
Country	:	US
Telephone Number	:	720-318-4615
Fax Number	:

Authorized Official
Title or Position	:	OWNER, SPEECH LANGUAGE PATHOLOGIST
Name	:	MRS. EMILY IRENE POLISEO
Credential	:	MA, CCC-SLP
Telephone Number	:	720-318-4615

Provider Enumeration Date	:	01/12/2015
Last Update Date	:	01/12/2015

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Directions to “PROACTIVE PEDIATRICS, LLC ” Practice Location

Language	Start Address	Practice Location

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