Provider Demographics
NPI:1851630123
Name:GUAJARDO, MIRTA (OTA)
Entity Type:Individual
Prefix:
First Name:MIRTA
Middle Name:
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 LOOP 20 STE. 5
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043
Mailing Address - Country:US
Mailing Address - Phone:956-712-9111
Mailing Address - Fax:
Practice Address - Street 1:3210 LOOP 20 STE. 5
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043
Practice Address - Country:US
Practice Address - Phone:956-712-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208668224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171436201Medicaid
TX171436201Medicaid