Healthcare Provider Details

I. General information

NPI: 1447997143
Provider Name (Legal Business Name): LAURA BAXTER OBUCHOWSKI M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 W LONG AVE
FORT WORTH TX
76106-5358
US

IV. Provider business mailing address

5253 AGAVE WAY
FORT WORTH TX
76126-3040
US

V. Phone/Fax

Practice location:
  • Phone: 817-814-4400
  • Fax: 817-814-4450
Mailing address:
  • Phone: 203-400-4356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number112525
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: