Provider Demographics
NPI:1588782171
Name:KOUDELKA, GARRY ANTHONY (CCC)
Entity type:Individual
Prefix:MR
First Name:GARRY
Middle Name:ANTHONY
Last Name:KOUDELKA
Suffix:
Gender:M
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17515 ADLONG SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:TX
Mailing Address - Zip Code:77532-4815
Mailing Address - Country:US
Mailing Address - Phone:281-328-2570
Mailing Address - Fax:
Practice Address - Street 1:17515 ADLONG SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:TX
Practice Address - Zip Code:77532-4815
Practice Address - Country:US
Practice Address - Phone:281-328-2570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist