Provider Demographics
NPI:1366604183
Name:STEPHEN F. AUSTIN STATE UNIVERSITY COLE AUDIOLOGY LAB
Entity type:Organization
Organization Name:STEPHEN F. AUSTIN STATE UNIVERSITY COLE AUDIOLOGY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BAKER
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:936-468-2201
Mailing Address - Street 1:1936 N STREET AUSTIN 315
Mailing Address - Street 2:PO BOX 6145, SFA STATION
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75962-0001
Mailing Address - Country:US
Mailing Address - Phone:936-468-2201
Mailing Address - Fax:936-468-2202
Practice Address - Street 1:2100 N RAGUET
Practice Address - Street 2:NO. 205
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961
Practice Address - Country:US
Practice Address - Phone:936-468-1252
Practice Address - Fax:936-468-7096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80104231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty