=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689803645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIGHT STAR THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2009
-----------------------------------------------------
Last Update Date | 07/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N FM 3167 SUITE 103
-----------------------------------------------------
City | RIO GRANDE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78582-6724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-263-1756
-----------------------------------------------------
Fax | 956-263-1758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 748
-----------------------------------------------------
City | RIO GRANDE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78582-0748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-263-1756
-----------------------------------------------------
Fax | 956-263-1758
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. LETICIA G. ROSA
-----------------------------------------------------
Credential | M.S. CCC-SLP
-----------------------------------------------------
Telephone | 956-735-9099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 102581
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------