MEDICARE: MRS. MICHELE THERESE PULVERMACHER MS 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	6097	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	80B68PU	OTHER	BCBS MN
2	HP32573	OTHER	HEALTH PARTNERS
3	4600498	OTHER	MEDICA

General Provider Information

NPI Number	:	1629172986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELE THERESE PULVERMACHER MS CCC SLP

Provider Business Mailing Address
First Line	:	PO BOX 34
Second Line	:
City	:	VICTORIA
State	:	MN
Zip	:	55386
Country	:	US
Telephone Number	:	952-443-9888
Fax Number	:	952-443-9804

Provider Business Practice Location Address
First Line	:	1772 STIEGER LAKE LANE
Second Line	:
City	:	VICTORIA
State	:	MN
Zip	:	55386
Country	:	US
Telephone Number	:	952-443-9888
Fax Number	:	952-443-9804

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

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	07/08/2007

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