MEDICARE: PEDSTEAM LLC

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

General Provider Information

NPI Number	:	1568191435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDSTEAM LLC

Provider Business Mailing Address
First Line	:	4228 VINEYARD DR E
Second Line	:
City	:	SOUTHAVEN
State	:	MS
Zip	:	38672-6068
Country	:	US
Telephone Number	:	870-476-5639
Fax Number	:

Provider Business Practice Location Address
First Line	:	6952 DOGWOOD MNR N STE 101
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-2090
Country	:	US
Telephone Number	:	662-932-4625
Fax Number	:	662-932-4626

Authorized Official
Title or Position	:	SPEECH-LANGUAGE PATHOLOGIST
Name	:	MRS. RACHEL LYNN JONES
Credential	:	MS, CCC-SLP
Telephone Number	:	870-476-5639

Provider Enumeration Date	:	06/07/2022
Last Update Date	:	10/03/2022

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Directions to “PEDSTEAM LLC ” Practice Location

Language	Start Address	Practice Location

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