=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104173368
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY AMBER STUART M.S. CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2012
-----------------------------------------------------
Last Update Date | 08/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 E CHASE AVE STE 204
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-647-6157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 NAUTILUS ST
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-390-5805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 20030
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------