Provider Demographics
NPI:1649470030
Name:APPLES AND BANANAS PEDIATRIC ORAL MOTOR AND DYSPHAGIA CENTER
Entity type:Organization
Organization Name:APPLES AND BANANAS PEDIATRIC ORAL MOTOR AND DYSPHAGIA CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:SERVANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:713-545-0349
Mailing Address - Street 1:3154 BONNEY BRIAR DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-3113
Mailing Address - Country:US
Mailing Address - Phone:713-545-0349
Mailing Address - Fax:
Practice Address - Street 1:3154 BONNEY BRIAR DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-3113
Practice Address - Country:US
Practice Address - Phone:713-545-0349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1376662064OtherNPI (INDIVIDUAL)