MEDICARE: MS. CALLIE JORDAN POULOS SLPL

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	SLPL5130	AZ

General Provider Information

NPI Number	:	1811036908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CALLIE JORDAN POULOS SLPL

Provider Business Mailing Address
First Line	:	1226 W OSBORN RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85013-3618
Country	:	US
Telephone Number	:	602-707-8624
Fax Number	:	602-707-2040

Provider Business Practice Location Address
First Line	:	1526 W MISSOURI AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2616
Country	:	US
Telephone Number	:	602-707-8624
Fax Number	:	602-707-2040

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	07/08/2007

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