MEDICARE: MRS. MARY KATHERINE MOSHER-STATHES LSLS CERT AVT

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	174H00000X	Health Educator	0454429	CO
2	2355S0801X	Speech-Language Assistant	70712246	CO

General Provider Information

NPI Number	:	1609170141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY KATHERINE MOSHER-STATHES LSLS CERT AVT

Provider Business Mailing Address
First Line	:	441 SAINT PAUL ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-4336
Country	:	US
Telephone Number	:	303-257-5943
Fax Number	:

Provider Business Practice Location Address
First Line	:	441 SAINT PAUL ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-4336
Country	:	US
Telephone Number	:	303-257-5943
Fax Number	:

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

Provider Enumeration Date	:	12/25/2010
Last Update Date	:	12/25/2010

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