=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558025114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA A IBARRA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2021
-----------------------------------------------------
Last Update Date | 10/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 S AIRPORT DR STE B
-----------------------------------------------------
City | WESLACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78596-6650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-375-2045
-----------------------------------------------------
Fax | 956-375-2046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2904 S JACKSON RD
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78503-1870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-631-8646
-----------------------------------------------------
Fax | 956-631-8650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 210017
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------