Provider Demographics
NPI:1295374627
Name:PEDIATRIC THERAPY ASSOCIATES-SPEECH, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY ASSOCIATES-SPEECH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:CCC/SLP
Authorized Official - Phone:361-853-0488
Mailing Address - Street 1:1001 LOUISIANA AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2856
Mailing Address - Country:US
Mailing Address - Phone:361-853-0488
Mailing Address - Fax:361-853-0489
Practice Address - Street 1:1001 LOUISIANA AVE STE 402
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2856
Practice Address - Country:US
Practice Address - Phone:361-853-0488
Practice Address - Fax:361-853-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363270501Medicaid