Provider Demographics
NPI:1851872659
Name:MONTALVO, MARISA
Entity Type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:MONTALVO
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 1:15302 JUDSON RD # 1318
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-1304
Mailing Address - Country:US
Mailing Address - Phone:361-945-7639
Mailing Address - Fax:
Practice Address - Street 1:600 N PEARL ST STE 1050
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-7495
Practice Address - Country:US
Practice Address - Phone:214-252-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213475224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant