Provider Demographics
NPI:1508346057
Name:LONGORIA, MARISA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:LONGORIA
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 1:413 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PALMVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:78572-6289
Mailing Address - Country:US
Mailing Address - Phone:956-360-0504
Mailing Address - Fax:
Practice Address - Street 1:1200 S BRYAN RD
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6840
Practice Address - Country:US
Practice Address - Phone:855-687-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084249225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant