Provider Demographics
NPI:1952879629
Name:ABRAHAM, RENU
Entity Type:Individual
Prefix:
First Name:RENU
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENU
Other - Middle Name:
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:647 BANBURY RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2177
Mailing Address - Country:US
Mailing Address - Phone:734-502-0112
Mailing Address - Fax:
Practice Address - Street 1:647 BANBURY RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2177
Practice Address - Country:US
Practice Address - Phone:734-502-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist