Provider Demographics
NPI:1700664836
Name:RUSDAL, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:RUSDAL
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 1:8537 STEEPLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-8325
Mailing Address - Country:US
Mailing Address - Phone:817-205-2889
Mailing Address - Fax:
Practice Address - Street 1:14005 RONALD W REAGAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78641-4631
Practice Address - Country:US
Practice Address - Phone:817-205-2889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121383235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist