Healthcare Provider Details

I. General information

NPI: 1114481348
Provider Name (Legal Business Name): PRECIOUS GBADAMOSI SLP-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NOLA RUTH BLVD
HARKER HEIGHTS TX
76548-1549
US

IV. Provider business mailing address

400 NOLA RUTH BLVD
HARKER HEIGHTS TX
76548-1549
US

V. Phone/Fax

Practice location:
  • Phone: 254-449-1405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: