MEDICARE: MRS. MICHELLE CAROL SOUTHERLY 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	394	WV

General Provider Information

NPI Number	:	1750407425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE CAROL SOUTHERLY SLP

Provider Business Mailing Address
First Line	:	RR 1 BOX 34 A
Second Line	:
City	:	AUGUSTA
State	:	WV
Zip	:	26704-9706
Country	:	US
Telephone Number	:	304-496-8284
Fax Number	:	304-496-9761

Provider Business Practice Location Address
First Line	:	RR 1 BOX 34 A
Second Line	:
City	:	AUGUSTA
State	:	WV
Zip	:	26704-9706
Country	:	US
Telephone Number	:	304-496-8284
Fax Number	:	304-496-9761

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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Directions to “ MRS. MICHELLE CAROL SOUTHERLY SLP” Practice Location

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