MEDICARE: KELLY GOWEN 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

General Provider Information

NPI Number	:	1487023537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY GOWEN CCC-SLP

Provider Business Mailing Address
First Line	:	7902 N 36TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68112-2023
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7902 N 36TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68112-2023
Country	:	US
Telephone Number	:	402-457-5818
Fax Number	:

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

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	09/18/2015

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Directions to “ KELLY GOWEN CCC-SLP” Practice Location

Language	Start Address	Practice Location

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