Provider Demographics
NPI:1255990727
Name:AUSTIN SPEECH PATHOLOGY, PLLC
Entity type:Organization
Organization Name:AUSTIN SPEECH PATHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:JENKINES
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:512-550-6857
Mailing Address - Street 1:711 W 38TH ST BLDG F2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1121
Mailing Address - Country:US
Mailing Address - Phone:512-550-6857
Mailing Address - Fax:
Practice Address - Street 1:711 W 38TH ST BLDG F2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1121
Practice Address - Country:US
Practice Address - Phone:512-550-6857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty