Healthcare Provider Details

I. General information

NPI: 1679628564
Provider Name (Legal Business Name): BONNIE JEAN BARTON ST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 RETAMA CIR
VICTORIA TX
77901-2765
US

IV. Provider business mailing address

4206 RETAMA CIR
VICTORIA TX
77901-2765
US

V. Phone/Fax

Practice location:
  • Phone: 361-582-0611
  • Fax: 361-582-4978
Mailing address:
  • Phone: 361-582-0611
  • Fax: 361-582-4978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17484
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: