MEDICARE: KYLIE DORMAN

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	117190	TX

General Provider Information

NPI Number	:	1700556354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLIE DORMAN

Provider Business Mailing Address
First Line	:	1401 CRESCENT RIDGE DR
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-4381
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4315 GREENS PRAIRIE TRL
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-2384
Country	:	US
Telephone Number	:	979-694-5870
Fax Number	:

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

Provider Enumeration Date	:	09/15/2021
Last Update Date	:	09/15/2021

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Directions to “ KYLIE DORMAN ” Practice Location

Language	Start Address	Practice Location

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