Provider Demographics
NPI:1649041765
Name:CAVAZOS, SAMUEL JARED
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JARED
Last Name:CAVAZOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 BIG CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-0659
Mailing Address - Country:US
Mailing Address - Phone:956-207-1082
Mailing Address - Fax:
Practice Address - Street 1:1250 NE 145TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-7134
Practice Address - Country:US
Practice Address - Phone:206-363-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123921225X00000X
WA61485467225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist