1750452397 NPI number — BRANDY MICHELLE BONEWALD SLP

Table of content: BRANDY MICHELLE BONEWALD SLP (NPI 1750452397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750452397 NPI number — BRANDY MICHELLE BONEWALD SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONEWALD
Provider First Name:
BRANDY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750452397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 WATER ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-5333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-792-3300
Provider Business Mailing Address Fax Number:
830-792-5771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 MARKET AVE
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-249-6067
Provider Business Practice Location Address Fax Number:
830-249-7051
Provider Enumeration Date:
11/13/2006

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:  101451 , 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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