MEDICARE: SPEECHLOGIC 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	235Z00000X	Speech-Language Pathologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H000MO2801	OTHER	TX	BLUE CROSS BLUE SHIELD
2	H08QH04601	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1669132726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPEECHLOGIC PLLC

Provider Business Mailing Address
First Line	:	PO BOX 962416
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79996-2416
Country	:	US
Telephone Number	:	940-290-0389
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 MCKINNEY AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-2519
Country	:	US
Telephone Number	:	915-929-5972
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	ELIZABETH YVONNE GOMEZ
Credential	:	MS, CCC-SLP
Telephone Number	:	915-929-5972

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	12/29/2021

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Directions to “SPEECHLOGIC PLLC ” Practice Location

Language	Start Address	Practice Location

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