MEDICARE: KELLY MALCOLM

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	146011711	IL

General Provider Information

NPI Number	:	1770944043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MALCOLM

Provider Business Mailing Address
First Line	:	1822 N CLEVELAND AVE
Second Line	:	APT. 1R
City	:	CHICAGO
State	:	IL
Zip	:	60614-5268
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1822 N CLEVELAND AVE
Second Line	:	APT. 1R
City	:	CHICAGO
State	:	IL
Zip	:	60614-5268
Country	:	US
Telephone Number	:	630-699-1607
Fax Number	:

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

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	03/15/2016

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Directions to “ KELLY MALCOLM ” Practice Location

Language	Start Address	Practice Location

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