MEDICARE: MRS. MARY ANNE KALLSEN MARY KALLSEN

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	1084	IA

General Provider Information

NPI Number	:	1962428615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ANNE KALLSEN MARY KALLSEN

Provider Business Mailing Address
First Line	:	32302 HICKORY AVE
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51108-8668
Country	:	US
Telephone Number	:	712-239-4789
Fax Number	:

Provider Business Practice Location Address
First Line	:	32302 HICKORY AVE
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51108-8668
Country	:	US
Telephone Number	:	712-239-4789
Fax Number	:

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	07/08/2007

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