MEDICARE: LILIANA MAYELA SOLIS BS, ASSISTANT 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	2355S0801X	Speech-Language Assistant	37620	TX

General Provider Information

NPI Number	:	1659883809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILIANA MAYELA SOLIS BS, ASSISTANT SLP

Provider Business Mailing Address
First Line	:	816 VAUGHN AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-3740
Country	:	US
Telephone Number	:	817-658-5679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 SUMMIT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-4403
Country	:	US
Telephone Number	:	817-546-8661
Fax Number	:

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

Provider Enumeration Date	:	10/27/2017
Last Update Date	:	10/27/2017

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