MEDICARE: NAZLI KHORRAMI BLACKWELL

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	112423	TX

General Provider Information

NPI Number	:	1750883682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NAZLI KHORRAMI BLACKWELL

Provider Business Mailing Address
First Line	:	PO BOX 162904
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78716-2904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4613 BEE CAVES RD STE 202
Second Line	:
City	:	WEST LAKE HILLS
State	:	TX
Zip	:	78746-5207
Country	:	US
Telephone Number	:	512-306-1707
Fax Number	:

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

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	03/07/2018

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