MEDICARE: MS. JEAN DOROTHY LIX M.S.

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	LL60076412	WA

General Provider Information

NPI Number	:	1801149257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN DOROTHY LIX M.S.

Provider Business Mailing Address
First Line	:	33330 8TH AVENUE SOUTH
Second Line	:
City	:	FEDERAL WAY
State	:	WA
Zip	:	98003
Country	:	US
Telephone Number	:	253-945-2086
Fax Number	:	253-945-2177

Provider Business Practice Location Address
First Line	:	2405 SOUTH 300TH
Second Line	:
City	:	FEDERAL WAY
State	:	WA
Zip	:	98003
Country	:	US
Telephone Number	:	253-945-4430
Fax Number	:	253-945-2177

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

Provider Enumeration Date	:	10/23/2012
Last Update Date	:	10/23/2012

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