MEDICARE: SANTA ROSA SPEECH & LANGUAGE SERVICES

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	SP1429	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992781421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA ROSA SPEECH & LANGUAGE SERVICES

Provider Business Mailing Address
First Line	:	4725B HOEN AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7862
Country	:	US
Telephone Number	:	707-542-1010
Fax Number	:	707-542-4818

Provider Business Practice Location Address
First Line	:	4725B HOEN AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7862
Country	:	US
Telephone Number	:	707-542-1010
Fax Number	:	707-542-4818

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN MAR SAMPLES
Credential	:	PHD
Telephone Number	:	707-542-1010

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	07/01/2008

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Directions to “SANTA ROSA SPEECH & LANGUAGE SERVICES ” Practice Location

Language	Start Address	Practice Location

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