Provider Demographics
NPI:1184930182
Name:THERAPY KORNER PEDIATRIC SERVICES
Entity type:Organization
Organization Name:THERAPY KORNER PEDIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MODESTA
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-445-3796
Mailing Address - Street 1:414 W. MAIN AVE.
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574
Mailing Address - Country:US
Mailing Address - Phone:956-445-3796
Mailing Address - Fax:
Practice Address - Street 1:414 W. MAIN AVE.
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78574
Practice Address - Country:US
Practice Address - Phone:956-445-3796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235500000X
TX335322355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty