MEDICARE: MRS. MISTY JO HILDUM M.S.

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	100030	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	741238418	OTHER	TX	EASTER SEALS GREATER HOUSTON

General Provider Information

NPI Number	:	1750469144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MISTY JO HILDUM M.S.

Provider Business Mailing Address
First Line	:	4888 LOOP CENTRAL DR STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-2227
Country	:	US
Telephone Number	:	713-838-9050
Fax Number	:	713-838-0926

Provider Business Practice Location Address
First Line	:	4888 LOOP CENTRAL DR STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77081-2227
Country	:	US
Telephone Number	:	713-838-9050
Fax Number	:	713-838-0926

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	12/16/2021

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