=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992283691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 806 SPEECH AND FEEDING THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2018
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5707 77TH ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-445-2899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5707 77TH ST
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-445-2899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH PATHOLOGIST
-----------------------------------------------------
Name | MRS. STACIE LYNN NEFFENDORF
-----------------------------------------------------
Credential | M.S., CCC-SLP
-----------------------------------------------------
Telephone | 806-445-2899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 106088
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------