Provider Demographics
NPI:1851899504
Name:CANTU, CAROLINA MARIA
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:MARIA
Last Name:CANTU
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 1:3506 CHANDLER LN
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:TX
Mailing Address - Zip Code:77536-6074
Mailing Address - Country:US
Mailing Address - Phone:281-917-4698
Mailing Address - Fax:
Practice Address - Street 1:9900 WESTPARK DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-5277
Practice Address - Country:US
Practice Address - Phone:713-528-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX402232355S0801X
TX118071235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX40223Medicaid