MEDICARE: MRS. KATHLEEN ELAM ROCKWELL SPEECH AND LANGUAGE

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	M461666505	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M461666505	OTHER	MO	MO HEALTHNET NATIONAL PROVIDER IDENTIFIER

General Provider Information

NPI Number	:	1851711451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN ELAM ROCKWELL SPEECH AND LANGUAGE

Provider Business Mailing Address
First Line	:	1917 POWDERHORN PASS CT
Second Line	:
City	:	WILDWOOD
State	:	MO
Zip	:	63011-1717
Country	:	US
Telephone Number	:	636-236-7806
Fax Number	:

Provider Business Practice Location Address
First Line	:	1917 POWDERHORN PASS CT
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-1717
Country	:	US
Telephone Number	:	636-236-7806
Fax Number	:

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

Provider Enumeration Date	:	04/22/2014
Last Update Date	:	04/22/2014

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Directions to “ MRS. KATHLEEN ELAM ROCKWELL SPEECH AND LANGUAGE” Practice Location

Language	Start Address	Practice Location

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