Provider Demographics
NPI:1639925100
Name:FIESTA THERAPEUTIC SERVICES LLC
Entity type:Organization
Organization Name:FIESTA THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:MSCCC-SLP
Authorized Official - Phone:956-408-0444
Mailing Address - Street 1:2537 OLD SPANISH TRL
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-9012
Mailing Address - Country:US
Mailing Address - Phone:956-408-0444
Mailing Address - Fax:
Practice Address - Street 1:2537 OLD SPANISH TRL
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-9012
Practice Address - Country:US
Practice Address - Phone:956-408-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty