MEDICARE: LILY MALLON CALKINS M.S., CF-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	2204001401	VA

General Provider Information

NPI Number	:	1922841519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILY MALLON CALKINS M.S., CF-SLP

Provider Business Mailing Address
First Line	:	4283 LLEWELLYN AVE UNIT 4283-208
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23504-1137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 DONNA DR STE 103
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6188
Country	:	US
Telephone Number	:	804-385-1116
Fax Number	:

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

Provider Enumeration Date	:	06/13/2024
Last Update Date	:	06/13/2024

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