1457083115 NPI number — ROBERTA ANN BIELITZ M.A., CCC-SLP

Table of content: ROBERTA ANN BIELITZ M.A., CCC-SLP (NPI 1457083115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457083115 NPI number — ROBERTA ANN BIELITZ M.A., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIELITZ
Provider First Name:
ROBERTA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAKER
Provider Other First Name:
ROBERTA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457083115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 GAYLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75044-6219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-977-9290
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 SAM HOUSTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75044-7507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-375-3020
Provider Business Practice Location Address Fax Number:
972-675-3025
Provider Enumeration Date:
06/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  108007 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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