MEDICARE: SPEECH LANGUAGE PATHOLOGY ASSOC INC

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	00671321

General Provider Information

NPI Number	:	1467433805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPEECH LANGUAGE PATHOLOGY ASSOC INC

Provider Business Mailing Address
First Line	:	4870 ARBORETUM DR
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48638-6371
Country	:	US
Telephone Number	:	989-792-1303
Fax Number	:

Provider Business Practice Location Address
First Line	:	4870 ARBORETUM DR
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48638-6371
Country	:	US
Telephone Number	:	989-792-1303
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. ELMO LE EUGENIO
Credential	:	MED CCC SLP
Telephone Number	:	989-792-1303

Provider Enumeration Date	:	11/11/2005
Last Update Date	:	08/22/2020

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