=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437420411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLORY BECK LINVILLE M.A./CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2012
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 E LEE AVE
-----------------------------------------------------
City | YADKINVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27055-8132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-679-8028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 CRAMERTON CT
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27023-9801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-262-6803
-----------------------------------------------------
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 | 9533
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------