MEDICARE: NIZA IRENE BALDERAS SPEECH ASSISTANT

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	2355S0801X	Speech-Language Assistant	38610	TX

General Provider Information

NPI Number	:	1639651946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIZA IRENE BALDERAS SPEECH ASSISTANT

Provider Business Mailing Address
First Line	:	5346 E US HIGHWAY 83 STE 2
Second Line	:
City	:	RIO GRANDE CITY
State	:	TX
Zip	:	78582-9418
Country	:	US
Telephone Number	:	956-317-1282
Fax Number	:	956-317-1291

Provider Business Practice Location Address
First Line	:	5346 EAST HIGHWAY 83 UNIT 2 BUILDING A
Second Line	:
City	:	RIO GRANDE CITY
State	:	TX
Zip	:	78582-7858
Country	:	US
Telephone Number	:	956-317-1282
Fax Number	:	956-317-1291

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

Provider Enumeration Date	:	09/04/2018
Last Update Date	:	09/04/2018

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