MEDICARE: FORT WORTH SPEECH THERAPY LLC

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

General Provider Information

NPI Number	:	1942840459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH SPEECH THERAPY LLC

Provider Business Mailing Address
First Line	:	5613 COVEY LN
Second Line	:
City	:	WICHITA FALLS
State	:	TX
Zip	:	76310-1788
Country	:	US
Telephone Number	:	817-995-4233
Fax Number	:

Provider Business Practice Location Address
First Line	:	6913 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7163
Country	:	US
Telephone Number	:	817-995-4233
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SLP
Name	:	ROBERT WINCOWSKI
Credential	:	SLP
Telephone Number	:	817-995-4233

Provider Enumeration Date	:	01/13/2020
Last Update Date	:	01/13/2020

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Directions to “FORT WORTH SPEECH THERAPY LLC ” Practice Location

Language	Start Address	Practice Location

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