Basic Information
| Provider Information | |||||||||
| NPI: | 1548562648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOW | ||||||||
| FirstName: | REAGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 RANCH ROAD 3237 | ||||||||
| Address2: | |||||||||
| City: | WIMBERLEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786765311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128475540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 RANCH ROAD 3237 | ||||||||
| Address2: | |||||||||
| City: | WIMBERLEY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786765311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128475540 | ||||||||
| FaxNumber: | 5128470419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2010 | ||||||||
| LastUpdateDate: | 10/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 105614 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.