Provider Demographics
NPI:1376329086
Name:BAZAN, JULISSA AIME
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:AIME
Last Name:BAZAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 SUNDANCE PKWY APT 3214
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-0035
Mailing Address - Country:US
Mailing Address - Phone:956-537-4137
Mailing Address - Fax:
Practice Address - Street 1:6051 FM 3009 STE 215
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-3473
Practice Address - Country:US
Practice Address - Phone:830-420-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist