=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427717446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA CRUZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2021
-----------------------------------------------------
Last Update Date | 12/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 EASTLAKE DR
-----------------------------------------------------
City | HORIZON CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79928-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-937-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 339 EMERALD CREEK DR
-----------------------------------------------------
City | HORIZON CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79928-6584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-433-5110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 105474
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------