MEDICARE: OVERTON SPEECH AND LANGUAGE CENTER

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	10222	TX

General Provider Information

NPI Number	:	1619159134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVERTON SPEECH AND LANGUAGE CENTER

Provider Business Mailing Address
First Line	:	4763 BARWICK DR
Second Line	:	SUITE 103
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1500
Country	:	US
Telephone Number	:	817-294-8408
Fax Number	:	817-294-8411

Provider Business Practice Location Address
First Line	:	4763 BARWICK DR
Second Line	:	SUITE 103
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1500
Country	:	US
Telephone Number	:	817-294-8408
Fax Number	:	817-294-8411

Authorized Official
Title or Position	:	SPEECH-LANGUAGE PATHOLOGIST
Name	:	VALERIE JOHNSTON
Credential	:	M.S., C.C.C.-S.L.P.
Telephone Number	:	817-294-8408

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	11/27/2007

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Directions to “OVERTON SPEECH AND LANGUAGE CENTER ” Practice Location

Language	Start Address	Practice Location

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