MEDICARE: GINA R SHONGO 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	SL006195L	PA

General Provider Information

NPI Number	:	1366572026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA R SHONGO MA CCC-SLP

Provider Business Mailing Address
First Line	:	757 FREDORIS ROAD
Second Line	:
City	:	STONEBORO
State	:	PA
Zip	:	16153
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	767 FREDORIS ROAD
Second Line	:
City	:	STONEBORO
State	:	PA
Zip	:	16153
Country	:	US
Telephone Number	:	724-988-9972
Fax Number	:

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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Directions to “ GINA R SHONGO MA CCC-SLP” Practice Location

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