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General NPI Number Information
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NPI Number | 1003552449
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Entity Type | Individual
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Provider Name | SHELLY DIANE CARROLL SLP-ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 05/09/2022
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Last Update Date | 05/09/2022
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Provider Practice Location Address
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Address Line | 605 E BROAD ST
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City | MANSFIELD
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State | TX
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Zip | 76063-1794
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Country | US
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Telephone | 817-299-6300
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Fax |
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Provider Business Mailing Address
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Address Line | 909 MASQUERADE DR
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City | MIDLOTHIAN
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State | TX
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Zip | 76065-8882
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Country | US
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Telephone | 817-658-3990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number | 32758
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License Number State | TX
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