MEDICARE: AGUSTIN DE LUCIO 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	107795	TX

General Provider Information

NPI Number	:	1760745905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGUSTIN DE LUCIO SLP

Provider Business Mailing Address
First Line	:	525 PALM HVN
Second Line	:
City	:	BROWNSVILLE
State	:	TX
Zip	:	78521-4122
Country	:	US
Telephone Number	:	956-459-8045
Fax Number	:	956-688-6336

Provider Business Practice Location Address
First Line	:	525 PALM HVN
Second Line	:
City	:	BROWNSVILLE
State	:	TX
Zip	:	78521-4122
Country	:	US
Telephone Number	:	956-459-8045
Fax Number	:	956-831-9931

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

Provider Enumeration Date	:	06/22/2012
Last Update Date	:	09/02/2014

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Directions to “ AGUSTIN DE LUCIO SLP” Practice Location

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