=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821441247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CHARM THERAPEUTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2016
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 GRAND OAKS CT
-----------------------------------------------------
City | ALVORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76225-6020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-577-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 GRAND OAKS CT
-----------------------------------------------------
City | ALVORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76225-6020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-577-4551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MRS. AMANDA GALE PENDLEY
-----------------------------------------------------
Credential | M.S., CCC-SLP
-----------------------------------------------------
Telephone | 940-577-4551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 111782
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 111699
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 107282
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 111652
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------