=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710412176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRING BRANCH SPEECH THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2017
-----------------------------------------------------
Last Update Date | 04/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12917 LAKE PARC BEND DR
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-6192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-382-1076
-----------------------------------------------------
Fax | 832-201-0759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12917 LAKE PARC BEND DR
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-6192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-382-1076
-----------------------------------------------------
Fax | 832-201-0759
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | JULIE WAHRENBERGER
-----------------------------------------------------
Credential | M.S., CCC-SLP
-----------------------------------------------------
Telephone | 281-382-1076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 103052
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------