MEDICARE: SMALL TALK SPEECH THERAPY LLC

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	22003447A	IN

General Provider Information

NPI Number	:	1649586157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALL TALK SPEECH THERAPY LLC

Provider Business Mailing Address
First Line	:	2229 CALAIS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9179
Country	:	US
Telephone Number	:	260-625-4323
Fax Number	:	260-625-3179

Provider Business Practice Location Address
First Line	:	2229 CALAIS RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9179
Country	:	US
Telephone Number	:	260-625-4323
Fax Number	:	260-625-3179

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. DEBRA KAY WYLIE
Credential	:	M.A.
Telephone Number	:	260-625-4323

Provider Enumeration Date	:	08/20/2010
Last Update Date	:	08/20/2010

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Directions to “SMALL TALK SPEECH THERAPY LLC ” Practice Location

Language	Start Address	Practice Location

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