MEDICARE: MRS. MARY SANDRA B. JUSTEN MSP, 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	SA3694	FL

General Provider Information

NPI Number	:	1639395247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY SANDRA B. JUSTEN MSP, CCC-SLP

Provider Business Mailing Address
First Line	:	CALLE ALVARO OBREGON
Second Line	:	COLONIA LAZARO CARDENAS
City	:	PUERTO ESCONDIDO
State	:	OAXACA
Zip	:	71980
Country	:	MX
Telephone Number	:	011529545823492
Fax Number	:

Provider Business Practice Location Address
First Line	:	12723 BARRETT DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-4101
Country	:	US
Telephone Number	:	813-514-7425
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/09/2007

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Directions to “ MRS. MARY SANDRA B. JUSTEN MSP, CCC-SLP” Practice Location

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