MEDICARE: LAURA JENNIFER NINE 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	9355	NC

General Provider Information

NPI Number	:	1629316377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JENNIFER NINE M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	10051 PERIMETER STATION DR
Second Line	:	APT. 203
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3358
Country	:	US
Telephone Number	:	336-549-2651
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 MT ISLE HARBOR DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-5405
Country	:	US
Telephone Number	:	704-258-1724
Fax Number	:

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

Provider Enumeration Date	:	01/30/2013
Last Update Date	:	01/30/2013

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