MEDICARE: ALEXANDRA ELIZABETH ANTONIO 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		MD

General Provider Information

NPI Number	:	1659937423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA ELIZABETH ANTONIO CCC-SLP

Provider Business Mailing Address
First Line	:	2931 DILLON ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-4834
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2931 DILLON ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21224-4834
Country	:	US
Telephone Number	:	630-294-7512
Fax Number	:

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

Provider Enumeration Date	:	05/16/2019
Last Update Date	:	05/16/2019

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