Healthcare Provider Details

I. General information

NPI: 1801474937
Provider Name (Legal Business Name): ELISA MARIEL VILLAZANA M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 CAMP BOWIE BLVD
FORT WORTH TX
76116-7119
US

IV. Provider business mailing address

4440 COLE ST
FORT WORTH TX
76115-2712
US

V. Phone/Fax

Practice location:
  • Phone: 817-814-2000
  • Fax:
Mailing address:
  • Phone: 817-522-2675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number122879
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: