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General NPI Number Information
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NPI Number | 1467713750
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Entity Type | Organization
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Legal Business Name | SPEECH DIVAS
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Dates
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Enumeration Date | 06/03/2012
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Last Update Date | 06/03/2012
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Provider Practice Location Address
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Address Line | 4229 PERIWINKLE DR
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City | FORT WORTH
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State | TX
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Zip | 76137-3013
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Country | US
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Telephone | 469-834-5742
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Fax |
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Provider Business Mailing Address
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Address Line | 4229 PERIWINKLE DR
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City | FORT WORTH
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State | TX
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Zip | 76137-3013
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Country | US
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Telephone | 469-834-5742
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Fax |
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Authorized Official
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Title or Position | SPEECH-LANGUAGE PATHOLOGIST
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Name | KATHY ANN PARK
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Credential | M.S., CCC-SLP
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Telephone | 817-371-3353
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number | 33891
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 19126
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License Number State | TX
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