Healthcare Provider Details

I. General information

NPI: 1255063673
Provider Name (Legal Business Name): FABIOLA FERNANDA CUELLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 N RAUL LONGORIA RD STE I
SAN JUAN TX
78589-3721
US

IV. Provider business mailing address

304 E 6TH ST
LOS FRESNOS TX
78566-3313
US

V. Phone/Fax

Practice location:
  • Phone: 956-782-5800
  • Fax:
Mailing address:
  • Phone: 210-956-7089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number118781
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: