Provider Demographics
NPI:1700071214
Name:MAIN STREET SPEECH THERAPY CLINIC
Entity Type:Organization
Organization Name:MAIN STREET SPEECH THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CARLON
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-650-4635
Mailing Address - Street 1:6622 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77009-1036
Mailing Address - Country:US
Mailing Address - Phone:281-650-4635
Mailing Address - Fax:
Practice Address - Street 1:6622 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77009-1036
Practice Address - Country:US
Practice Address - Phone:281-650-4635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty