Provider Demographics
NPI:1477290427
Name:BHAKTA, KOMAL TUSHAR (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:KOMAL
Middle Name:TUSHAR
Last Name:BHAKTA
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-2615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3501 S LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1139
Practice Address - Country:US
Practice Address - Phone:806-796-1774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118107235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist