MEDICARE: KELLY W. ROBERTSON

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	4897	LA

General Provider Information

NPI Number	:	1154570398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY W. ROBERTSON

Provider Business Mailing Address
First Line	:	4228 GRAND MARAIS RD
Second Line	:
City	:	JENNINGS
State	:	LA
Zip	:	70546-8273
Country	:	US
Telephone Number	:	337-288-9418
Fax Number	:

Provider Business Practice Location Address
First Line	:	4228 GRAND MARAIS RD
Second Line	:
City	:	JENNINGS
State	:	LA
Zip	:	70546-8273
Country	:	US
Telephone Number	:	337-288-9418
Fax Number	:

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

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	09/11/2008

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