MEDICARE: MS. BRANDY ELAINE PRINCE M.H.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		IL

General Provider Information

NPI Number	:	1902097363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRANDY ELAINE PRINCE M.H.S

Provider Business Mailing Address
First Line	:	3002 W WALNUT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1847
Country	:	US
Telephone Number	:	773-410-0006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3002 W WALNUT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1847
Country	:	US
Telephone Number	:	773-410-0006
Fax Number	:

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

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	08/09/2007

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