Provider Demographics
NPI:1265663553
Name:FERTITTA, DARRAGH ELIZABETTA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DARRAGH
Middle Name:ELIZABETTA
Last Name:FERTITTA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:DARRAGH
Other - Middle Name:ELIZABETA-LYNN
Other - Last Name:FERTITTA-BOUTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:700 SCOTT AND WHITE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6441
Practice Address - Country:US
Practice Address - Phone:979-207-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7432235Z00000X
TX111932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist