Provider Demographics
NPI:1114302171
Name:WALCOTT, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S LHS DR APT 229
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-8749
Mailing Address - Country:US
Mailing Address - Phone:409-221-1726
Mailing Address - Fax:
Practice Address - Street 1:115 S LHS DR APT 229
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657-8749
Practice Address - Country:US
Practice Address - Phone:409-221-1726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112221235Z00000X
NMSLP7230235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist