MEDICARE: MICHAEL MASCOLO 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	2204000175	VA

General Provider Information

NPI Number	:	1790255198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MASCOLO SLP

Provider Business Mailing Address
First Line	:	2605 ARABIAN DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-8027
Country	:	US
Telephone Number	:	251-979-3119
Fax Number	:

Provider Business Practice Location Address
First Line	:	2213 ROUND HILL DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8855
Country	:	US
Telephone Number	:	757-648-2520
Fax Number	:

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

Provider Enumeration Date	:	11/28/2018
Last Update Date	:	11/28/2018

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Directions to “ MICHAEL MASCOLO SLP” Practice Location

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