Provider Demographics
NPI:1720698392
Name:GARZA, GUSTAVO AXEL
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:AXEL
Last Name:GARZA
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 1:1505 CALLE DEL NORTE STE 440
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6040
Mailing Address - Country:US
Mailing Address - Phone:956-722-6221
Mailing Address - Fax:956-722-6275
Practice Address - Street 1:1505 CALLE DEL NORTE STE 440
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6040
Practice Address - Country:US
Practice Address - Phone:956-722-6221
Practice Address - Fax:956-722-6275
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120946225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist