Healthcare Provider Details

I. General information

NPI: 1649654211
Provider Name (Legal Business Name): CLARISSA IDROGO OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 N MALINCHE AVE
LAREDO TX
78043-3354
US

IV. Provider business mailing address

1232 SAINT PATRICK DR
LAREDO TX
78045-7593
US

V. Phone/Fax

Practice location:
  • Phone: 956-722-2431
  • Fax: 956-722-7553
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number116904
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: