MEDICARE: FULL SPECTRUM THERAPY SERVICES, PLLC

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	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1699372888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL SPECTRUM THERAPY SERVICES, PLLC

Provider Business Mailing Address
First Line	:	7637 HENDERSON PARK RD
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-6366
Country	:	US
Telephone Number	:	248-703-5924
Fax Number	:

Provider Business Practice Location Address
First Line	:	7637 HENDERSON PARK RD
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-6366
Country	:	US
Telephone Number	:	248-703-5924
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	DR. DIANCA M EDWARDS
Credential	:	SLP
Telephone Number	:	248-703-5924

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	10/01/2020

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