MEDICARE: MRS. GWEN C. MACE-WALKER MS.CCC-SP

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	SP#635	AR

General Provider Information

NPI Number	:	1942476429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GWEN C. MACE-WALKER MS.CCC-SP

Provider Business Mailing Address
First Line	:	3205 JENNY LIND RD
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-7101
Country	:	US
Telephone Number	:	479-785-2501
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 JENNY LIND RD
Second Line	:
City	:	FT SMITH
State	:	AR
Zip	:	72901
Country	:	US
Telephone Number	:	479-785-2501
Fax Number	:

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

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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