1720065808 NPI number — MR. KELLYE JAROSZ SLP

Table of content: CAMERON MOORE HIS (NPI 1831626399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720065808 NPI number — MR. KELLYE JAROSZ SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAROSZ
Provider First Name:
KELLYE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720065808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 E. LONDON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-825-5061
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 E. LONDON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOWIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-825-5061
Provider Business Practice Location Address Fax Number:
940-766-4943
Provider Enumeration Date:
12/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  100364 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100364 . This is a "HUMANA ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".