Provider Demographics
NPI:1609439157
Name:LO, JUSTIN WEI (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WEI
Last Name:LO
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 TARRANT LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-5293
Mailing Address - Country:US
Mailing Address - Phone:908-672-8504
Mailing Address - Fax:
Practice Address - Street 1:6301 GASTON AVE STE 750
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3922
Practice Address - Country:US
Practice Address - Phone:214-295-5374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111468235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist