MEDICARE: LITTLE SPROUT SPEECH, LLC

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	252Y00000X	Early Intervention Provider Agency	06297	MD

General Provider Information

NPI Number	:	1972903359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE SPROUT SPEECH, LLC

Provider Business Mailing Address
First Line	:	11908 BRISTOL MANOR CT
Second Line	:
City	:	NORTH BETHESDA
State	:	MD
Zip	:	20852-5804
Country	:	US
Telephone Number	:	301-943-0920
Fax Number	:	240-260-1450

Provider Business Practice Location Address
First Line	:	11908 BRISTOL MANOR CT
Second Line	:
City	:	NORTH BETHESDA
State	:	MD
Zip	:	20852-5804
Country	:	US
Telephone Number	:	301-943-0920
Fax Number	:	240-260-1450

Authorized Official
Title or Position	:	OWNER
Name	:	HALLIE BULKIN
Credential	:	MA CCC-SLP
Telephone Number	:	301-943-0920

Provider Enumeration Date	:	09/03/2014
Last Update Date	:	09/03/2014

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