Healthcare Provider Details

I. General information

NPI: 1558876334
Provider Name (Legal Business Name): CAITLYN PURKS CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2017
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SOUTH ST STE 300
VIDOR TX
77662-6183
US

IV. Provider business mailing address

9386 N HIGHWAY 6
CRAWFORD TX
76638-2849
US

V. Phone/Fax

Practice location:
  • Phone: 254-644-2770
  • Fax: 254-848-4193
Mailing address:
  • Phone: 254-644-2423
  • Fax: 254-848-4193

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:
Title or Position:
Credential:
Phone: