MEDICARE: BLUE SKY SPEECH AND FEEDING THERAPY PLLC

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	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1629839386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE SKY SPEECH AND FEEDING THERAPY PLLC

Provider Business Mailing Address
First Line	:	3621 WINIFRED DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2126
Country	:	US
Telephone Number	:	618-792-8034
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 WINIFRED DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2126
Country	:	US
Telephone Number	:	618-792-8034
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA MARIE MOORE
Credential	:	CCC-SLP
Telephone Number	:	618-792-8034

Provider Enumeration Date	:	01/19/2024
Last Update Date	:	01/19/2024

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