=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720191844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI A MAYO SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 09/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6101 N STATE LINE AVE
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-791-2299
-----------------------------------------------------
Fax | 903-793-0058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2902 NORTHVIEW ST
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-1562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-314-1903
-----------------------------------------------------
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 | 100348
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 1600
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------