MEDICARE: MRS. HOLLY B MULVENNA 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	146006538	IL

General Provider Information

NPI Number	:	1922258557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HOLLY B MULVENNA M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	2307 W ROSCOE ST
Second Line	:	UNIT 1W
City	:	CHICAGO
State	:	IL
Zip	:	60618-6245
Country	:	US
Telephone Number	:	773-972-0864
Fax Number	:

Provider Business Practice Location Address
First Line	:	2307 W ROSCOE ST
Second Line	:	UNIT 1W
City	:	CHICAGO
State	:	IL
Zip	:	60618-6245
Country	:	US
Telephone Number	:	773-972-0864
Fax Number	:

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

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	09/18/2008

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