Provider Demographics
NPI:1619243243
Name:BEACON THERAPY RESOURCE, LLC
Entity Type:Organization
Organization Name:BEACON THERAPY RESOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:
Authorized Official - First Name:CATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:830-773-2400
Mailing Address - Street 1:342 E RIO GRANDE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-4812
Mailing Address - Country:US
Mailing Address - Phone:830-773-2400
Mailing Address - Fax:830-773-8020
Practice Address - Street 1:342 E RIO GRANDE ST
Practice Address - Street 2:SUITE A
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-4812
Practice Address - Country:US
Practice Address - Phone:830-773-2400
Practice Address - Fax:830-773-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17977235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170523803Medicaid