{
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"FirstLineMailingAddress": "2336 SHALLOW CREEK LN",
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"MailingAddressCityName": "FRIENDSWOOD",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "77546-1506",
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"FirstLinePracticeLocationAddress": "2045 SPACE PARK DR STE 140",
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"PracticeLocationAddressCityName": "HOUSTON",
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"PracticeLocationAddressFaxNumber": "832-769-3059",
"EnumerationDate": "05/01/2019",
"LastUpdateDate": "09/25/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
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"AuthorizedOfficialLastName": "BRACEY",
"AuthorizedOfficialFirstName": "KISA",
"AuthorizedOfficialMiddleName": "JEANNETTE",
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"AuthorizedOfficialCredential": "CCC-SLP",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "235Z00000X",
"TaxonomyName": "Speech-Language Pathologist",
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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}
}
}
}