MEDICARE: ANDREA LARY CCC-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
1	235Z00000X	Speech-Language Pathologist	692	SC

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508824061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA LARY CCC-SLP

Provider Business Mailing Address
First Line	:	PO BOX 1523
Second Line	:
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-1523
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3803 PALMETTO DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5944
Country	:	US
Telephone Number	:	843-455-7505
Fax Number	:	866-668-9946

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	11/14/2012

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Directions to “ ANDREA LARY CCC-SLP” Practice Location

Language	Start Address	Practice Location

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