MEDICARE: MALLORY ROBERTS

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	SLP-4224	ID

General Provider Information

NPI Number	:	1720610645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY ROBERTS

Provider Business Mailing Address
First Line	:	2662 JOSHUA WAY
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-8953
Country	:	US
Telephone Number	:	801-663-9765
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 2ND AVE E
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-6425
Country	:	US
Telephone Number	:	208-749-3475
Fax Number	:

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

Provider Enumeration Date	:	02/08/2020
Last Update Date	:	02/08/2020

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Directions to “ MALLORY ROBERTS ” Practice Location

Language	Start Address	Practice Location

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