MEDICARE: MRS. AUDREY MALLOY MA CCC-SLP

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	235Z00000X	Speech-Language Pathologist	3812	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043289309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AUDREY MALLOY MA CCC-SLP

Provider Business Mailing Address
First Line	:	3021 RIVER OAKS DR
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71201-2029
Country	:	US
Telephone Number	:	318-348-5701
Fax Number	:	318-388-0774

Provider Business Practice Location Address
First Line	:	3021 RIVER OAKS DR
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71201-2029
Country	:	US
Telephone Number	:	318-348-5701
Fax Number	:	318-388-0774

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

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	05/01/2008

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