MEDICARE: HILARY SAMPLE 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	SP.13921	OH

General Provider Information

NPI Number	:	1548997943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HILARY SAMPLE CCC-SLP

Provider Business Mailing Address
First Line	:	10307 DETROIT AVE UNIT 302
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-1605
Country	:	US
Telephone Number	:	440-458-1311
Fax Number	:

Provider Business Practice Location Address
First Line	:	10307 DETROIT AVE UNIT 302
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-1605
Country	:	US
Telephone Number	:	440-458-1311
Fax Number	:

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

Provider Enumeration Date	:	08/04/2022
Last Update Date	:	08/04/2022

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Directions to “ HILARY SAMPLE CCC-SLP” Practice Location

Language	Start Address	Practice Location

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