MEDICARE: LAURA LYNN MADDIN 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	2018043052	MO
2	235Z00000X	Speech-Language Pathologist	2440511	IL

General Provider Information

NPI Number	:	1679138994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA LYNN MADDIN SLP

Provider Business Mailing Address
First Line	:	621 ROCKHAMPTON DR
Second Line	:
City	:	COLUMBIA
State	:	IL
Zip	:	62236-2700
Country	:	US
Telephone Number	:	314-828-5115
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 S RAPP AVE
Second Line	:
City	:	COLUMBIA
State	:	IL
Zip	:	62236-2326
Country	:	US
Telephone Number	:	618-281-4995
Fax Number	:

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

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	05/02/2019

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Directions to “ LAURA LYNN MADDIN SLP” Practice Location

Language	Start Address	Practice Location

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