MEDICARE: MB THERAPY

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417359431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MB THERAPY

Provider Business Mailing Address
First Line	:	5401C JACKSON ST
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2322
Country	:	US
Telephone Number	:	318-278-0740
Fax Number	:

Provider Business Practice Location Address
First Line	:	5401C JACKSON ST
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71303-2322
Country	:	US
Telephone Number	:	318-278-0740
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. MEGAN BOLTON
Credential	:	SLP
Telephone Number	:	318-278-0740

Provider Enumeration Date	:	09/22/2014
Last Update Date	:	09/22/2014

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Directions to “MB THERAPY ” Practice Location

Language	Start Address	Practice Location

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