Provider Demographics
NPI:1538713631
Name:TRAILBLAZER SPEECH THERAPY PLLC
Entity type:Organization
Organization Name:TRAILBLAZER SPEECH THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:972-839-1833
Mailing Address - Street 1:8001 CENTERVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-4228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 W PURNELL RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3918
Practice Address - Country:US
Practice Address - Phone:469-713-5203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty