MEDICARE: EXECUTIVE THERAPY & EDUCATIONAL SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	103798	TX

General Provider Information

NPI Number	:	1558594614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE THERAPY & EDUCATIONAL SERVICES INC

Provider Business Mailing Address
First Line	:	2660 HOLLY HALL ST APT C
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-4190
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11601 SHADOW CREEK PKWY
Second Line	:	111-196
City	:	PEARLAND
State	:	TX
Zip	:	77584-7283
Country	:	US
Telephone Number	:	281-787-2422
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRYSTAL PRATT
Credential	:
Telephone Number	:	281-300-5526

Provider Enumeration Date	:	08/24/2009
Last Update Date	:	08/24/2009

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