Provider Demographics
NPI:1093341281
Name:ROMERO MONDRAGON, MARICARMEN
Entity Type:Individual
Prefix:
First Name:MARICARMEN
Middle Name:
Last Name:ROMERO MONDRAGON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARICARMEN
Other - Middle Name:
Other - Last Name:ROMERO-MONDRAGON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:8001 S INTERSTATE 35 APT 1923
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-0012
Mailing Address - Country:US
Mailing Address - Phone:512-709-9757
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:682-365-2598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist