Provider Demographics
NPI:1255357414
Name:BRAZOSPORT SPEECH PATHOLOGY SERVICES, PLLC
Entity type:Organization
Organization Name:BRAZOSPORT SPEECH PATHOLOGY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:DANETTE
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:979-480-0333
Mailing Address - Street 1:460 PLANTATION DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566
Mailing Address - Country:US
Mailing Address - Phone:979-480-0333
Mailing Address - Fax:979-480-0316
Practice Address - Street 1:460 PLANTATION DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566
Practice Address - Country:US
Practice Address - Phone:979-480-0333
Practice Address - Fax:979-480-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16308235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty