Provider Demographics
NPI:1720743727
Name:TEAGUE, BIANCA NICOLE (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:NICOLE
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CHAMPIONS PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-3799
Mailing Address - Country:US
Mailing Address - Phone:915-236-2000
Mailing Address - Fax:
Practice Address - Street 1:100 CHAMPIONS PL
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3799
Practice Address - Country:US
Practice Address - Phone:915-236-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11072010Other1