MEDICARE: KAITLYN OLIVIA WALLS M.S., CCC-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	4711	AL
2	235Z00000X	Speech-Language Pathologist	121743	TX

General Provider Information

NPI Number	:	1841060068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN OLIVIA WALLS M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	7517 VILLA ROSA DR APT 7212
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2331
Country	:	US
Telephone Number	:	256-656-0810
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 BRYAN AVE STE 220
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2420
Country	:	US
Telephone Number	:	817-885-4200
Fax Number	:

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

Provider Enumeration Date	:	01/08/2024
Last Update Date	:	01/08/2024

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Directions to “ KAITLYN OLIVIA WALLS M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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