MEDICARE: J. OLIVER SPEECH PATHOLOGY SERVICES, INC.

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	252Y00000X	Early Intervention Provider Agency	SA 1466	FL
2	252Y00000X	Early Intervention Provider Agency	SA1466	FL

General Provider Information

NPI Number	:	1699958603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. OLIVER SPEECH PATHOLOGY SERVICES, INC.

Provider Business Mailing Address
First Line	:	4831 DIXIANA DR
Second Line	:
City	:	BOWLING GREEN
State	:	FL
Zip	:	33834-5050
Country	:	US
Telephone Number	:	863-375-9996
Fax Number	:	863-375-9993

Provider Business Practice Location Address
First Line	:	4831 DIXIANA DR
Second Line	:
City	:	BOWLING GREEN
State	:	FL
Zip	:	33834-5050
Country	:	US
Telephone Number	:	863-375-9996
Fax Number	:	863-375-9993

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JOYCE FULSE
Credential	:	CCC/SLP
Telephone Number	:	863-375-9996

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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