MEDICARE: MARY PELLEGRINO M.A. 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	SA2251	FL

General Provider Information

NPI Number	:	1609998509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY PELLEGRINO M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	3708 FOXFORD CIR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32309-3314
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3215 CAPITAL MEDICAL BLVD
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-4413
Country	:	US
Telephone Number	:	850-878-0609
Fax Number	:	850-877-1057

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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