Provider Demographics
NPI:1295065480
Name:GANDARA, SUOMI LOPEZ (SLP-A)
Entity type:Individual
Prefix:
First Name:SUOMI
Middle Name:LOPEZ
Last Name:GANDARA
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 VIA MIRAMONTE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-3055
Mailing Address - Country:US
Mailing Address - Phone:972-686-3312
Mailing Address - Fax:
Practice Address - Street 1:5316 TRAIL LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-1931
Practice Address - Country:US
Practice Address - Phone:817-292-8787
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX352322355A2700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX456606Medicare PIN
TX149984001Medicaid