MEDICARE: MARY KAY WILLIS SLPA

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	2355S0801X	Speech-Language Assistant	35255	TX

General Provider Information

NPI Number	:	1811223324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KAY WILLIS SLPA

Provider Business Mailing Address
First Line	:	1248 AUSTIN HWY
Second Line	:	SUITE 210
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-4821
Country	:	US
Telephone Number	:	210-646-8008
Fax Number	:	210-646-8242

Provider Business Practice Location Address
First Line	:	1248 AUSTIN HWY
Second Line	:	SUITE 210
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-4821
Country	:	US
Telephone Number	:	210-646-8008
Fax Number	:	210-646-8242

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

Provider Enumeration Date	:	10/19/2009
Last Update Date	:	10/19/2009

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