MEDICARE: MISS KATHLEEN V SHOUP 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	021307-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	008786	OTHER	NY	STATE EDUCATION DEPARTMENT
2	01133216	OTHER	NY	AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION

General Provider Information

NPI Number	:	1528349222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KATHLEEN V SHOUP CCC-SLP

Provider Business Mailing Address
First Line	:	35 WOODBINE PARK
Second Line	:
City	:	GENESEO
State	:	NY
Zip	:	14454-1184
Country	:	US
Telephone Number	:	585-455-5719
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 AVON RD
Second Line	:
City	:	GENESEO
State	:	NY
Zip	:	14454
Country	:	US
Telephone Number	:	585-243-3450
Fax Number	:

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

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	06/13/2018

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Directions to “ MISS KATHLEEN V SHOUP CCC-SLP” Practice Location

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