Provider Demographics
NPI:1457978488
Name:DEVORA, MARISELA
Entity Type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:DEVORA
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 1:215 N AVENUE Q
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TX
Mailing Address - Zip Code:76634-1233
Mailing Address - Country:US
Mailing Address - Phone:254-326-8230
Mailing Address - Fax:
Practice Address - Street 1:700 S 4TH ST APT 1114
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-1075
Practice Address - Country:US
Practice Address - Phone:254-326-8230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116802235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist