MEDICARE: ANNETTE RAK 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

General Provider Information

NPI Number	:	1770841462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNETTE RAK CCC-SLP

Provider Business Mailing Address
First Line	:	4022 E GREENWAY RD
Second Line	:	SUITE 11-122
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4797
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4022 E GREENWAY RD
Second Line	:	SUITE 11-122
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4797
Country	:	US
Telephone Number	:	123-456-7890
Fax Number	:

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

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	05/31/2015

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Directions to “ ANNETTE RAK CCC-SLP” Practice Location

Language	Start Address	Practice Location

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