MEDICARE: PROFESSIONAL SPEECH SERVICES 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	01270	MN

General Provider Information

NPI Number	:	1568800076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SPEECH SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 64317
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55164-0317
Country	:	US
Telephone Number	:	507-434-9177
Fax Number	:	515-270-0539

Provider Business Practice Location Address
First Line	:	308 4TH AVE NW
Second Line	:
City	:	AUSTIN
State	:	MN
Zip	:	55912-3140
Country	:	US
Telephone Number	:	507-434-9177
Fax Number	:	515-270-0539

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	KRISTINA SHUPE
Credential	:	SLP
Telephone Number	:	507-434-9177

Provider Enumeration Date	:	06/06/2013
Last Update Date	:	11/15/2013

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