MEDICARE: MS. CHAN THAI LUONG CCC-SLP

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	41075804	TX

General Provider Information

NPI Number	:	1417497884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHAN THAI LUONG CCC-SLP

Provider Business Mailing Address
First Line	:	4413 KOEHLER ST UNIT E
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3592
Country	:	US
Telephone Number	:	316-519-1795
Fax Number	:

Provider Business Practice Location Address
First Line	:	4413 KOEHLER ST UNIT E
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-3592
Country	:	US
Telephone Number	:	316-519-1795
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2017
Last Update Date	:	04/18/2023

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