Provider Demographics
NPI:1558667931
Name:POPE, KYLIE D (SLP-INTERN)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:D
Last Name:POPE
Suffix:
Gender:F
Credentials:SLP-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 PARK PLACE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1300
Mailing Address - Country:US
Mailing Address - Phone:817-921-5020
Mailing Address - Fax:817-921-5022
Practice Address - Street 1:1617 PARK PLACE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1300
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:817-921-5022
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1064852355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX207164901Medicaid
TX676535Medicare PIN