Provider Demographics
NPI:1437473089
Name:ABC PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:ABC PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:505-891-2590
Mailing Address - Street 1:3308 OASIS SPRINGS RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-2579
Mailing Address - Country:US
Mailing Address - Phone:505-980-3051
Mailing Address - Fax:505-892-7359
Practice Address - Street 1:3308 OASIS SPRINGS RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2579
Practice Address - Country:US
Practice Address - Phone:505-891-2590
Practice Address - Fax:505-892-7359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78682908Medicaid