MEDICARE: GROW AND BLOSSOM SPEECH AND LANGUAGE SERVICES, PLLC

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	018511-1	NY

General Provider Information

NPI Number	:	1578804449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROW AND BLOSSOM SPEECH AND LANGUAGE SERVICES, PLLC

Provider Business Mailing Address
First Line	:	13529 COOLIDGE AVE
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11435-1037
Country	:	US
Telephone Number	:	718-440-7478
Fax Number	:	347-532-1315

Provider Business Practice Location Address
First Line	:	3427 STEINWAY ST
Second Line	:	SUITE 116
City	:	ASTORIA
State	:	NY
Zip	:	11101-8606
Country	:	US
Telephone Number	:	718-440-7478
Fax Number	:	347-532-1315

Authorized Official
Title or Position	:	BILINGUAL SLP
Name	:	MS. DOLLY CRISTINA GUTIERREZ
Credential	:	MA CCC-SLP
Telephone Number	:	718-440-7478

Provider Enumeration Date	:	03/02/2013
Last Update Date	:	03/02/2013

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