MEDICARE: ALEXA NICOLE LONGSWORTH M.S 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

General Provider Information

NPI Number	:	1598275810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXA NICOLE LONGSWORTH M.S CCC-SLP

Provider Business Mailing Address
First Line	:	3950 N LAKE SHORE DR APT 2114
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5103
Country	:	US
Telephone Number	:	773-349-0415
Fax Number	:

Provider Business Practice Location Address
First Line	:	3950 N LAKE SHORE DR APT 2114
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5103
Country	:	US
Telephone Number	:	773-349-0415
Fax Number	:

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

Provider Enumeration Date	:	10/02/2017
Last Update Date	:	07/20/2020

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