=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790487676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRE'ANNA VALENZUELA M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2023
-----------------------------------------------------
Last Update Date | 04/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7801 N RICHLAND BLVD
-----------------------------------------------------
City | NORTH RICHLAND HILLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76180-6415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-307-4561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6529 WOODDALE DR
-----------------------------------------------------
City | WATAUGA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76148-2854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-307-4561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 111924
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------