Healthcare Provider Details

I. General information

NPI: 1720290109
Provider Name (Legal Business Name): BRANDI WUBBENA MS CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 LONE STAR DR
DALLAS TX
75212-6313
US

IV. Provider business mailing address

5918 FAWN MEADOW TRL
ARLINGTON TX
76017-1975
US

V. Phone/Fax

Practice location:
  • Phone: 214-467-9787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number101604
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: