Provider Demographics
NPI:1750469144
Name:HILDUM, MISTY JO (MS)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:JO
Last Name:HILDUM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4888 LOOP CENTRAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-2227
Mailing Address - Country:US
Mailing Address - Phone:713-838-9050
Mailing Address - Fax:713-838-0926
Practice Address - Street 1:4888 LOOP CENTRAL DR STE 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-2227
Practice Address - Country:US
Practice Address - Phone:713-838-9050
Practice Address - Fax:713-838-0926
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX741238418OtherEASTER SEALS GREATER HOUSTON