Provider Demographics
NPI:1467176511
Name:WALLER, BAILEE ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BAILEE
Middle Name:ANN
Last Name:WALLER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 NE CINDY LN
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-3434
Mailing Address - Country:US
Mailing Address - Phone:214-532-6154
Mailing Address - Fax:
Practice Address - Street 1:2500 N WALNUT CREEK DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4287
Practice Address - Country:US
Practice Address - Phone:919-424-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118351235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118351OtherAMERICAN SPEECH LANGUAGE HEARING ASSOCIATION LICENSE NUMBER