Healthcare Provider Details

I. General information

NPI: 1053571125
Provider Name (Legal Business Name): ALICIA MARIE INGERSOLL M.S.CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 DURANGO SPRINGS DR
HASLET TX
76052-3563
US

IV. Provider business mailing address

1265 DURANGO SPRINGS DR
HASLET TX
76052-3563
US

V. Phone/Fax

Practice location:
  • Phone: 817-905-0578
  • Fax:
Mailing address:
  • Phone: 817-905-0578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number104421
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: