MEDICARE: EZ PEDIATRIC 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	2355S0801X	Speech-Language Assistant	33153	TX

General Provider Information

NPI Number	:	1356655666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZ PEDIATRIC THERAPY

Provider Business Mailing Address
First Line	:	11711 SHADOW CREEK PKWY STE 113
Second Line	:
City	:	PEARLAND
State	:	TX
Zip	:	77584-7233
Country	:	US
Telephone Number	:	832-289-5663
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 W OREM DR
Second Line	:	SUITE 500
City	:	HOUSTON
State	:	TX
Zip	:	77085-1276
Country	:	US
Telephone Number	:	832-289-5663
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LA SONJA HENDERSON
Credential	:	SLP- ASSISTANT
Telephone Number	:	832-289-5663

Provider Enumeration Date	:	07/28/2010
Last Update Date	:	05/10/2013

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