Healthcare Provider Details

I. General information

NPI: 1366929341
Provider Name (Legal Business Name): MARA FACHA MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARA RINCON

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9514 CONSOLE DR STE 102
SAN ANTONIO TX
78229-2042
US

IV. Provider business mailing address

9514 CONSOLE DR STE 102
SAN ANTONIO TX
78229-2042
US

V. Phone/Fax

Practice location:
  • Phone: 210-448-9111
  • Fax: 210-340-1259
Mailing address:
  • Phone: 210-448-9111
  • Fax: 210-340-1259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number118276
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: