MEDICARE: MARY TERESA MOSHURE M.A. CCC-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	SA16198	FL

General Provider Information

NPI Number	:	1912483140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY TERESA MOSHURE M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	2837 TISHMAN AVE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-3937
Country	:	US
Telephone Number	:	941-257-2031
Fax Number	:

Provider Business Practice Location Address
First Line	:	1006 N MILLS AVE
Second Line	:
City	:	ARCADIA
State	:	FL
Zip	:	34266-8811
Country	:	US
Telephone Number	:	863-494-8450
Fax Number	:

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

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/11/2018

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