MEDICARE: MADELINE D DETTORRE

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	SP.16051	OH

General Provider Information

NPI Number	:	1467279315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE D DETTORRE

Provider Business Mailing Address
First Line	:	1111 SUPERIOR AVE E STE 1800
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44114-2500
Country	:	US
Telephone Number	:	330-635-6562
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 E 55TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-4406
Country	:	US
Telephone Number	:	330-635-6562
Fax Number	:

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

Provider Enumeration Date	:	09/23/2024
Last Update Date	:	09/24/2024

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Directions to “ MADELINE D DETTORRE ” Practice Location

Language	Start Address	Practice Location

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