MEDICARE: MS. CHERYL ANN OTERMAT MACCCSLP

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	22002898A	IN

General Provider Information

NPI Number	:	1902027550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHERYL ANN OTERMAT MACCCSLP

Provider Business Mailing Address
First Line	:	1650 LYNDON FARM CT
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-5002
Country	:	US
Telephone Number	:	502-412-5847
Fax Number	:	502-412-0407

Provider Business Practice Location Address
First Line	:	1650 LYNDON FARM CT
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-5002
Country	:	US
Telephone Number	:	502-412-5847
Fax Number	:	502-412-0407

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	04/08/2009

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