Provider Demographics
NPI:1871724229
Name:ESCAMILLA, KELLY RACHEL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RACHEL
Last Name:ESCAMILLA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 AUSTIN HWY
Mailing Address - Street 2:STE 210
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4821
Mailing Address - Country:US
Mailing Address - Phone:210-646-8008
Mailing Address - Fax:
Practice Address - Street 1:1248 AUSTIN HWY
Practice Address - Street 2:STE 210
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4821
Practice Address - Country:US
Practice Address - Phone:210-646-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752850036Medicaid