MEDICARE: KELLY WEAVER M.A., 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	12129156

General Provider Information

NPI Number	:	1316232234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY WEAVER M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	709 GOODRICH CT
Second Line	:
City	:	PLATTEVILLE
State	:	CO
Zip	:	80651-7586
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	709 GOODRICH CT
Second Line	:
City	:	PLATTEVILLE
State	:	CO
Zip	:	80651-7586
Country	:	US
Telephone Number	:	214-995-3432
Fax Number	:

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

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	05/10/2019

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Directions to “ KELLY WEAVER M.A., CCC-SLP” Practice Location

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