Provider Demographics
NPI:1811614647
Name:GOBER, MICA LEIGH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICA
Middle Name:LEIGH
Last Name:GOBER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9881 BELLA CT
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-2167
Mailing Address - Country:US
Mailing Address - Phone:432-559-5058
Mailing Address - Fax:
Practice Address - Street 1:804 N SAM HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-3973
Practice Address - Country:US
Practice Address - Phone:432-456-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118716235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist