MEDICARE: YOUR SPEECH THERAPIST, 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	235Z00000X	Speech-Language Pathologist	SA2045	FL

General Provider Information

NPI Number	:	1710255492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR SPEECH THERAPIST, INC.

Provider Business Mailing Address
First Line	:	8178 SANDPIPER GLEN DRIVE
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-6946
Country	:	US
Telephone Number	:	954-778-8876
Fax Number	:

Provider Business Practice Location Address
First Line	:	8178 SANDPIPER GLEN DRIVE
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-6946
Country	:	US
Telephone Number	:	954-778-8867
Fax Number	:

Authorized Official
Title or Position	:	PRES
Name	:	MARC H MITNICK
Credential	:	MS/CCC-SLP
Telephone Number	:	954-778-8876

Provider Enumeration Date	:	12/08/2011
Last Update Date	:	06/04/2012

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Directions to “YOUR SPEECH THERAPIST, INC. ” Practice Location

Language	Start Address	Practice Location

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