MEDICARE: MRS. DONNA WILKINSON BRODEN 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	1842	TX

General Provider Information

NPI Number	:	1760617179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA WILKINSON BRODEN SLP

Provider Business Mailing Address
First Line	:	1321 ROWAN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-3033
Country	:	US
Telephone Number	:	214-392-5776
Fax Number	:	214-821-3160

Provider Business Practice Location Address
First Line	:	1321 ROWAN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-3033
Country	:	US
Telephone Number	:	214-392-5776
Fax Number	:	214-821-6130

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

Provider Enumeration Date	:	05/29/2009
Last Update Date	:	05/29/2009

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