MEDICARE: MRS. SHELLY DIANE CARROLL SLP-ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	32758	TX

General Provider Information

NPI Number	:	1003552449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHELLY DIANE CARROLL SLP-ASSISTANT

Provider Business Mailing Address
First Line	:	909 MASQUERADE DR
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-8882
Country	:	US
Telephone Number	:	817-658-3990
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 E BROAD ST
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-1794
Country	:	US
Telephone Number	:	817-299-6300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2022
Last Update Date	:	05/09/2022

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Directions to “ MRS. SHELLY DIANE CARROLL SLP-ASSISTANT” Practice Location

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