Healthcare Provider Details

I. General information

NPI: 1043450737
Provider Name (Legal Business Name): COASTAL BEND SPEECH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N MONROE ST
BEEVILLE TX
78102-4433
US

IV. Provider business mailing address

4866 TAYLOR DR
BEEVILLE TX
78102-8467
US

V. Phone/Fax

Practice location:
  • Phone: 361-354-4387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number103784
License Number StateTX

VIII. Authorized Official

Name: MRS. JENNIFER ANN GONZALES
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential:
Phone: 361-354-4387