=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992467146
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANDA KAY SEVERSON SLP INTERN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2021
-----------------------------------------------------
Last Update Date | 10/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14651 DALLAS PKWY STE 200
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75254-8856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-680-5743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 MARKETPLACE DR APT 822
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76711-2445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-679-0196
-----------------------------------------------------
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 | 119053
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------