Healthcare Provider Details

I. General information

NPI: 1336626332
Provider Name (Legal Business Name): CRISELDA CAVAZOS MS,CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

85 NE LOOP 410 STE 500
SAN ANTONIO TX
78216-5866
US

IV. Provider business mailing address

1129 W SAGE RD
KINGSVILLE TX
78363-2790
US

V. Phone/Fax

Practice location:
  • Phone: 210-822-0475
  • Fax: 210-822-0485
Mailing address:
  • Phone: 361-228-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: