Provider Demographics
NPI:1073920617
Name:THEBADO, ALYCIA MICHELE (SLP)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:MICHELE
Last Name:THEBADO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7838 HUEBNER RD
Mailing Address - Street 2:APT 4309
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3167
Mailing Address - Country:US
Mailing Address - Phone:732-908-9604
Mailing Address - Fax:
Practice Address - Street 1:7838 HUEBNER RD
Practice Address - Street 2:APT 4309
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3167
Practice Address - Country:US
Practice Address - Phone:732-908-9604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist