Provider Demographics
NPI:1245017813
Name:LONGBRAKE, ERICCA
Entity type:Individual
Prefix:
First Name:ERICCA
Middle Name:
Last Name:LONGBRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 EVERS RD BLDG D
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1606
Mailing Address - Country:US
Mailing Address - Phone:210-397-8762
Mailing Address - Fax:
Practice Address - Street 1:100 GROSENBACHER RD N
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-4716
Practice Address - Country:US
Practice Address - Phone:210-397-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116083235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist