MEDICARE: PAIGE PONTHIER FAULDER MS 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	24969	TX

General Provider Information

NPI Number	:	1578704441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAIGE PONTHIER FAULDER MS CCC-SLP

Provider Business Mailing Address
First Line	:	6732 E PARK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3747
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 EDWARDS RANCH RD
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4116
Country	:	US
Telephone Number	:	817-377-1254
Fax Number	:

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

Provider Enumeration Date	:	03/23/2009
Last Update Date	:	09/28/2016

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