MEDICARE: MRS. KELLY LYNN WITTENAUER M.S. 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	2009012464	MO

General Provider Information

NPI Number	:	1508188046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY LYNN WITTENAUER M.S. SLP

Provider Business Mailing Address
First Line	:	401 BALLWIN ESTATES CT.
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63021
Country	:	US
Telephone Number	:	314-749-4744
Fax Number	:

Provider Business Practice Location Address
First Line	:	17770 MUELLER RD.
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63038
Country	:	US
Telephone Number	:	314-749-4744
Fax Number	:

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

Provider Enumeration Date	:	02/25/2010
Last Update Date	:	01/30/2017

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