Basic Information
| Provider Information | |||||||||
| NPI: | 1003995481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'LEARY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.S., CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8173783699 | ||||||||
| Practice Location | |||||||||
| Address1: | 5801 OAKBEND TRL STE 260 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761323923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173466000 | ||||||||
| FaxNumber: | 8173466009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2006 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 51096 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 282481501 | 05 | TX | MEDICAID |