Provider Demographics
NPI:1194259465
Name:FAHRENTHOLD, ALYSSA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:FAHRENTHOLD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6516 SAINT JOHNS DR APT 3047
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76132-5804
Mailing Address - Country:US
Mailing Address - Phone:512-633-4884
Mailing Address - Fax:
Practice Address - Street 1:2620 SCRIPTURE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-4315
Practice Address - Country:US
Practice Address - Phone:940-297-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112415235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist