MEDICARE: MITZI PUEBLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	116810	TX

General Provider Information

NPI Number	:	1346987245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITZI PUEBLA

Provider Business Mailing Address
First Line	:	4223 BRIARGROVE LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-6604
Country	:	US
Telephone Number	:	469-752-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	4223 BRIARGROVE LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-6604
Country	:	US
Telephone Number	:	469-752-2800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2022
Last Update Date	:	04/24/2023

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Directions to “ MITZI PUEBLA ” Practice Location

Language	Start Address	Practice Location

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