Provider Demographics
NPI:1912486598
Name:SALOME, SALLY LIANA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:LIANA
Last Name:SALOME
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3701
Mailing Address - Country:US
Mailing Address - Phone:956-456-9022
Mailing Address - Fax:
Practice Address - Street 1:1300 CARL RAMERT DR
Practice Address - Street 2:
Practice Address - City:YOAKUM
Practice Address - State:TX
Practice Address - Zip Code:77995-4869
Practice Address - Country:US
Practice Address - Phone:361-293-2801
Practice Address - Fax:361-293-7751
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111352235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist