=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447845078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUN RISES SPEECH & LANGUAGE SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2021
-----------------------------------------------------
Last Update Date | 01/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25928 HAYNIE FLAT RD
-----------------------------------------------------
City | SPICEWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78669-1483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-644-0736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 432
-----------------------------------------------------
City | SPICEWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78669-0432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-644-0736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | JACQUELINE CRISTY BANCAYAN-TOMLIN
-----------------------------------------------------
Credential | M.S., CCC-SLP
-----------------------------------------------------
Telephone | 512-644-0736
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------