Provider Demographics
NPI:1033644596
Name:PINEY WOODS SPEECH PATHOLOGY, PLLC
Entity Type:Organization
Organization Name:PINEY WOODS SPEECH PATHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DESPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC/SLP
Authorized Official - Phone:409-202-5002
Mailing Address - Street 1:526 S WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4540
Mailing Address - Country:US
Mailing Address - Phone:409-202-5002
Mailing Address - Fax:844-848-9342
Practice Address - Street 1:526 S WHEELER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4540
Practice Address - Country:US
Practice Address - Phone:409-202-5002
Practice Address - Fax:844-848-9342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty