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General NPI Number Information
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NPI Number | 1396505731
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Entity Type | Individual
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Provider Name | CALLIE WILMORE M.S.
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Gender | Female
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Dates
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Enumeration Date | 03/21/2024
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Last Update Date | 03/21/2024
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Provider Practice Location Address
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Address Line | 1149 W 190TH ST STE 2300
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City | GARDENA
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State | CA
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Zip | 90248-4350
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Country | US
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Telephone | 310-892-5812
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Fax |
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Provider Business Mailing Address
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Address Line | 236 MANHATTAN AVE APT 2
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City | HERMOSA BEACH
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State | CA
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Zip | 90254-5133
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Country | US
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Telephone | 901-413-1307
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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 | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 18989
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License Number State | CA
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