Provider Demographics
NPI:1700366465
Name:BACA, CORNELIO (SLP-ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CORNELIO
Middle Name:
Last Name:BACA
Suffix:
Gender:M
Credentials:SLP-ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E REDBUD AVE STE 5A
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-4673
Mailing Address - Country:US
Mailing Address - Phone:956-353-9508
Mailing Address - Fax:866-610-1692
Practice Address - Street 1:901 E REDBUD AVE STE 5A
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-4673
Practice Address - Country:US
Practice Address - Phone:956-353-9508
Practice Address - Fax:866-610-1692
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346012355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant