Healthcare Provider Details

I. General information

NPI: 1174777197
Provider Name (Legal Business Name): LISA MARICELA GUERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 GARDENDALE ST # 106
SAN ANTONIO TX
78229-3182
US

IV. Provider business mailing address

2823 LAKEHILLS ST
SAN ANTONIO TX
78251-1718
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-0222
  • Fax:
Mailing address:
  • Phone: 210-692-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number101614
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: