Provider Demographics
NPI:1598124141
Name:DE ANDA, CRISELDA
Entity Type:Individual
Prefix:
First Name:CRISELDA
Middle Name:
Last Name:DE ANDA
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 1:1704 N KENYON RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78542-1484
Mailing Address - Country:US
Mailing Address - Phone:956-566-7861
Mailing Address - Fax:
Practice Address - Street 1:912 S CLOSNER BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-5600
Practice Address - Country:US
Practice Address - Phone:956-566-7861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT107949225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist