MEDICARE: MARY MILLER TATUM M.ED, 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	SA11089	FL

General Provider Information

NPI Number	:	1700107448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY MILLER TATUM M.ED, CCC-SLP

Provider Business Mailing Address
First Line	:	122 EGLIN PKWY NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4917
Country	:	US
Telephone Number	:	850-863-9973
Fax Number	:	850-863-9974

Provider Business Practice Location Address
First Line	:	122 EGLIN PKWY NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4917
Country	:	US
Telephone Number	:	850-863-9973
Fax Number	:	850-863-9974

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

Provider Enumeration Date	:	06/16/2010
Last Update Date	:	09/06/2011

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