Provider Demographics
NPI:1003391947
Name:CARVALLO, BERTHA ALICIA (CNA)
Entity type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:ALICIA
Last Name:CARVALLO
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 FILLMORE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930
Mailing Address - Country:US
Mailing Address - Phone:915-566-0353
Mailing Address - Fax:
Practice Address - Street 1:2725 FILLMORE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930
Practice Address - Country:US
Practice Address - Phone:915-566-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLHOC14-00102253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency