Provider Demographics
NPI:1972240166
Name:409 THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:409 THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:409-289-1426
Mailing Address - Street 1:139 PRIVATE ROAD 5396
Mailing Address - Street 2:
Mailing Address - City:KIRBYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75956-3235
Mailing Address - Country:US
Mailing Address - Phone:409-289-1426
Mailing Address - Fax:
Practice Address - Street 1:139 PRIVATE ROAD 5396
Practice Address - Street 2:
Practice Address - City:KIRBYVILLE
Practice Address - State:TX
Practice Address - Zip Code:75956-3235
Practice Address - Country:US
Practice Address - Phone:409-449-5498
Practice Address - Fax:409-449-6079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-18
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1457784167Medicaid