Provider Demographics
NPI:1811152978
Name:ROSA, LETICIA G (SLP)
Entity type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:G
Last Name:ROSA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-0748
Mailing Address - Country:US
Mailing Address - Phone:956-735-9099
Mailing Address - Fax:956-849-3786
Practice Address - Street 1:201 N FM 3167
Practice Address - Street 2:SUITE 103
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-6724
Practice Address - Country:US
Practice Address - Phone:956-263-1756
Practice Address - Fax:956-263-1758
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102581235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX022017001Medicaid
TX676501Medicare PIN