Healthcare Provider Details

I. General information

NPI: 1043040496
Provider Name (Legal Business Name): CIERRA CORDOVA RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S AW GRIMES BLVD
ROUND ROCK TX
78664-2854
US

IV. Provider business mailing address

8229 AREZZO DR
ROUND ROCK TX
78665-4516
US

V. Phone/Fax

Practice location:
  • Phone: 512-677-9339
  • Fax:
Mailing address:
  • Phone: 512-635-1306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-364709
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: