MEDICARE: SUE CAVALLIN MA, 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	2195-154	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659472215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE CAVALLIN MA, CCC-SLP

Provider Business Mailing Address
First Line	:	2900 CURRY LN
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5857
Country	:	US
Telephone Number	:	920-468-1161
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 CURRY LN
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5857
Country	:	US
Telephone Number	:	920-468-1161
Fax Number	:

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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