Provider Demographics
NPI:1285030049
Name:JUAREZ, DENISE (OTR)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:JUAREZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:BOUKOUENDJI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:620 N ALLEGHANEY AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4408
Mailing Address - Country:US
Mailing Address - Phone:432-332-8244
Mailing Address - Fax:432-580-7428
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-335-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114764225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114764OtherSTATE LICENSE