=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063972388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE COMMUNICATION CLUBHOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2019
-----------------------------------------------------
Last Update Date | 03/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9747 BROKEN BOW RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75238-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-952-2684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9747 BROKEN BOW RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75238-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-952-2684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | NICOLE GONZALEZ DEVOSS
-----------------------------------------------------
Credential | JD, MS, CCC-SLP
-----------------------------------------------------
Telephone | 214-952-2684
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------