MEDICARE: MARY RICHARDSON MA 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	22004744A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12147615	OTHER	IN	ASHA
2	22004744A	OTHER	IL	IPLA

General Provider Information

NPI Number	:	1962964064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY RICHARDSON MA CCC-SLP

Provider Business Mailing Address
First Line	:	5930 HALLOWELL PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6214
Country	:	US
Telephone Number	:	260-409-0687
Fax Number	:

Provider Business Practice Location Address
First Line	:	5930 HALLOWELL PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6214
Country	:	US
Telephone Number	:	260-409-0687
Fax Number	:

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

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	04/05/2019

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