Provider Demographics
NPI:1417318627
Name:XPRESSIVELY YOURZ SPEECH THERAPY SERVICES
Entity Type:Organization
Organization Name:XPRESSIVELY YOURZ SPEECH THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:SHAVONNE
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MED,CCC-SLP
Authorized Official - Phone:281-451-2567
Mailing Address - Street 1:15622 CLARKS FORK CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77086-1173
Mailing Address - Country:US
Mailing Address - Phone:281-397-0882
Mailing Address - Fax:
Practice Address - Street 1:14511 FALLING CREEK DR
Practice Address - Street 2:SUITE 205
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-1244
Practice Address - Country:US
Practice Address - Phone:281-397-0882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101249235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196943801Medicaid