MEDICARE: BLUEBONNET THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1225765886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET THERAPY

Provider Business Mailing Address
First Line	:	9535 TEAKWOOD DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78266-2352
Country	:	US
Telephone Number	:	210-816-4575
Fax Number	:

Provider Business Practice Location Address
First Line	:	9535 TEAKWOOD DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78266-2352
Country	:	US
Telephone Number	:	210-816-4575
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARISSA TIJERINA
Credential	:
Telephone Number	:	361-549-9189

Provider Enumeration Date	:	08/04/2022
Last Update Date	:	08/04/2022

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Directions to “BLUEBONNET THERAPY ” Practice Location

Language	Start Address	Practice Location

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