Provider Demographics
NPI:1790085090
Name:GARCIA, DIANA (MS, CCC, SLP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GARCIA
Suffix:
Gender:F
Credentials:MS, CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 PARK PLACE AVE
Mailing Address - Street 2:#110
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1300
Mailing Address - Country:US
Mailing Address - Phone:817-921-5020
Mailing Address - Fax:817-921-5022
Practice Address - Street 1:1617 PARK PLACE AVE
Practice Address - Street 2:#110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1300
Practice Address - Country:US
Practice Address - Phone:817-921-5020
Practice Address - Fax:817-921-5022
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN
TX149984001Medicaid