MEDICARE: KELLI A MAYO 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	100348	TX
2	235Z00000X	Speech-Language Pathologist	1600	AR

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	:	1720191844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI A MAYO SLP

Provider Business Mailing Address
First Line	:	2902 NORTHVIEW ST
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-1562
Country	:	US
Telephone Number	:	903-314-1903
Fax Number	:

Provider Business Practice Location Address
First Line	:	6101 N STATE LINE AVE
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-5309
Country	:	US
Telephone Number	:	903-791-2299
Fax Number	:	903-793-0058

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

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	09/28/2012

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Directions to “ KELLI A MAYO SLP” Practice Location

Language	Start Address	Practice Location

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