MEDICARE: KELLY R CROSS M.S. 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	6782	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720105539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY R CROSS M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	1700 NANTUCKETT LN
Second Line	:	#106
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-2304
Country	:	US
Telephone Number	:	704-654-6119
Fax Number	:	704-708-9499

Provider Business Practice Location Address
First Line	:	1700 NANTUCKETT LN
Second Line	:	#106
City	:	CHARLOTTE
State	:	NC
Zip	:	28270-2304
Country	:	US
Telephone Number	:	704-654-6119
Fax Number	:	704-708-9499

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

Provider Enumeration Date	:	03/25/2007
Last Update Date	:	07/08/2007

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