Healthcare Provider Details

I. General information

NPI: 1659095784
Provider Name (Legal Business Name): NORTHWEST ISD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 FM 3433
NEWARK TX
76071-5431
US

IV. Provider business mailing address

654 FM 3433
NEWARK TX
76071-5431
US

V. Phone/Fax

Practice location:
  • Phone: 817-698-1713
  • Fax:
Mailing address:
  • Phone: 817-698-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JESSICA ROSE
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 817-698-1713