Provider Demographics
NPI:1780038968
Name:CERDA, CORIE (MAT, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:CORIE
Middle Name:
Last Name:CERDA
Suffix:
Gender:F
Credentials:MAT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27600 KINGS MANOR DR N APT 1763
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2169
Mailing Address - Country:US
Mailing Address - Phone:512-818-6038
Mailing Address - Fax:
Practice Address - Street 1:2520 WW THORNE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77073-3406
Practice Address - Country:US
Practice Address - Phone:281-449-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
TXAT71482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program