Healthcare Provider Details

I. General information

NPI: 1871035113
Provider Name (Legal Business Name): BIANCA CENTENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 PREMIER DR
IRVING TX
75063-2661
US

IV. Provider business mailing address

8004 WEST AVE STE 2
SAN ANTONIO TX
78213-1870
US

V. Phone/Fax

Practice location:
  • Phone: 972-756-1222
  • Fax:
Mailing address:
  • Phone: 210-340-2627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23496
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: