Provider Demographics
NPI:1013279561
Name:DIAZ-CHAVEZ, SUSANA
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:DIAZ-CHAVEZ
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 1:1101 E SCHUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4659
Mailing Address - Country:US
Mailing Address - Phone:915-544-8484
Mailing Address - Fax:833-272-3454
Practice Address - Street 1:1101 E SCHUSTER AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-544-8484
Practice Address - Fax:833-272-3454
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107785235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN