MEDICARE: BRIDGING THE GAP SPEECH THERAPY, LLC

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	SP#2130	AR

General Provider Information

NPI Number	:	1720315088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGING THE GAP SPEECH THERAPY, LLC

Provider Business Mailing Address
First Line	:	4101 S CHATFIELD RD
Second Line	:
City	:	BAUXITE
State	:	AR
Zip	:	72011-9012
Country	:	US
Telephone Number	:	501-350-2770
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 S CHATFIELD RD
Second Line	:
City	:	BAUXITE
State	:	AR
Zip	:	72011-9012
Country	:	US
Telephone Number	:	501-350-2770
Fax Number	:

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	CAROLE DENISE WALKER
Credential	:	M.S., CCC-SLP
Telephone Number	:	501-350-2770

Provider Enumeration Date	:	11/06/2009
Last Update Date	:	11/06/2009

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