Provider Demographics
NPI:1982186649
Name:CARDWELL, THERESA MARIE (BA, SLP-ASSISTANT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:CARDWELL
Suffix:
Gender:F
Credentials:BA, SLP-ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 RIDGE RUN ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-4112
Mailing Address - Country:US
Mailing Address - Phone:210-414-9336
Mailing Address - Fax:
Practice Address - Street 1:5510 RIDGE RUN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-4112
Practice Address - Country:US
Practice Address - Phone:210-414-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX014682251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578708483Medicaid