Provider Demographics
NPI:1770156408
Name:DE LA GARZA, ITZEL ARIADNA
Entity type:Individual
Prefix:
First Name:ITZEL
Middle Name:ARIADNA
Last Name:DE LA GARZA
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 1:12527 ELEMINA TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4561
Mailing Address - Country:US
Mailing Address - Phone:210-986-8914
Mailing Address - Fax:
Practice Address - Street 1:815 SYCAMORE MOON
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-8032
Practice Address - Country:US
Practice Address - Phone:904-638-6388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician