MEDICARE: SCOTT JEFFREY LEBERG MS, 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	2518-154	WI

General Provider Information

NPI Number	:	1669647632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT JEFFREY LEBERG MS, CCC-SLP

Provider Business Mailing Address
First Line	:	4721 BROOKSHIRE CT
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-9795
Country	:	US
Telephone Number	:	715-423-1555
Fax Number	:

Provider Business Practice Location Address
First Line	:	4721 BROOKSHIRE CT
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-9795
Country	:	US
Telephone Number	:	715-423-1555
Fax Number	:

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

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/29/2008

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