Julie    Bonomo    SLP
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004719
NPI
1518114552
Tax ID
163621518
Effective Date
4/1/2012
Last Updated
10/22/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
1424 Mechanic Street
Galveston, TX 77550
United States
County
Galveston
Phone
4092565343 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Speech Pathology
Map
Address