MEDICARE: MRS. JOHNWANETTA MESHAE GRAYSON-RODGERS M.A., CCC-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	12106351	TX

General Provider Information

NPI Number	:	1992088033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOHNWANETTA MESHAE GRAYSON-RODGERS M.A., CCC-SLP

Provider Business Mailing Address
First Line	:	10703 COYOTE HL
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-2415
Country	:	US
Telephone Number	:	210-854-7073
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 GARDENDALE ST STE 200A
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3143
Country	:	US
Telephone Number	:	210-615-7837
Fax Number	:

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

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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