MEDICARE: LACEY BISHOP

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	108895	TX

General Provider Information

NPI Number	:	1811315229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY BISHOP

Provider Business Mailing Address
First Line	:	1810 TURNER RIDGE DR
Second Line	:	APT 9209
City	:	FORT WORTH
State	:	TX
Zip	:	76110-7436
Country	:	US
Telephone Number	:	214-793-8255
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 TURNER RIDGE DR
Second Line	:	APT 9209
City	:	FORT WORTH
State	:	TX
Zip	:	76110-7436
Country	:	US
Telephone Number	:	214-793-8255
Fax Number	:

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

Provider Enumeration Date	:	04/02/2014
Last Update Date	:	04/02/2014

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Directions to “ LACEY BISHOP ” Practice Location

Language	Start Address	Practice Location

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