MEDICARE: IVELISSE HERNANDEZ-OBESO MS, 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	SA9639	FL

General Provider Information

NPI Number	:	1386892123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVELISSE HERNANDEZ-OBESO MS, CCC-SLP

Provider Business Mailing Address
First Line	:	15532 SW 142ND CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33177-1044
Country	:	US
Telephone Number	:	305-238-9967
Fax Number	:

Provider Business Practice Location Address
First Line	:	7100 SW 99TH AVE
Second Line	:	SUITE 201
City	:	MIAMI
State	:	FL
Zip	:	33173-4667
Country	:	US
Telephone Number	:	305-491-1032
Fax Number	:

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

Provider Enumeration Date	:	09/05/2008
Last Update Date	:	09/05/2008

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Directions to “ IVELISSE HERNANDEZ-OBESO MS, CCC-SLP” Practice Location

Language	Start Address	Practice Location

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