MEDICARE: CODY BRONDON CULBREATH

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	6548	LA

General Provider Information

NPI Number	:	1487274049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY BRONDON CULBREATH

Provider Business Mailing Address
First Line	:	206 IXWORTH AVE
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-7100
Country	:	US
Telephone Number	:	318-331-6993
Fax Number	:

Provider Business Practice Location Address
First Line	:	1736 IRVING PL
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-4606
Country	:	US
Telephone Number	:	318-221-1983
Fax Number	:

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

Provider Enumeration Date	:	04/23/2020
Last Update Date	:	04/23/2020

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Directions to “ CODY BRONDON CULBREATH ” Practice Location

Language	Start Address	Practice Location

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