Provider Demographics
NPI:1023777505
Name:MAGNOLIA SPEECH AND LANGUAGE THERAPY, PLLC
Entity type:Organization
Organization Name:MAGNOLIA SPEECH AND LANGUAGE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:512-883-0504
Mailing Address - Street 1:4120 TIN TAQEL PATH
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-4851
Mailing Address - Country:US
Mailing Address - Phone:845-926-2525
Mailing Address - Fax:
Practice Address - Street 1:4120 TIN TAQEL PATH
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-4851
Practice Address - Country:US
Practice Address - Phone:845-926-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
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
NC1982112363Medicaid