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NPI Code Detail

MEDICARE: MALLORY MARIE BONIFAS MA, CF SLP

MEDICARE: MALLORY MARIE BONIFAS MA, CF 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
1235Z00000XSpeech-Language PathologistSZ4193FL

General Provider Information

NPI Number : 1477888303
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALLORY MARIE BONIFAS MA, CF SLP
Provider Business Mailing Address
First Line : 2130 MORGAN WIELAND LANE
Second Line : APT 304
City : LAKELAND
State : FL
Zip : 33813
Country : US
Telephone Number : 419-302-2878
Fax Number :
Provider Business Practice Location Address
First Line : 1215 E ORANGE ST
Second Line :
City : LAKELAND
State : FL
Zip : 33801-5762
Country : US
Telephone Number : 863-802-3800
Fax Number : 863-802-0480
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/09/2009
Last Update Date : 10/09/2009

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