MEDICARE: JEROMA LYNN VICINO 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

General Provider Information

NPI Number	:	1366913329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEROMA LYNN VICINO MA CCC SLP

Provider Business Mailing Address
First Line	:	400 N WEST AVE
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-2128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 N WEST AVE
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-2128
Country	:	US
Telephone Number	:	630-834-5562
Fax Number	:

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

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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