Provider Demographics
NPI:1811299720
Name:FUNTASTIC KIDS THERAPY
Entity type:Organization
Organization Name:FUNTASTIC KIDS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:M S CCC-SLP
Authorized Official - Phone:956-718-2020
Mailing Address - Street 1:1501 E. BUSTAMANTE SUITE G
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041
Mailing Address - Country:US
Mailing Address - Phone:956-718-2020
Mailing Address - Fax:956-718-2919
Practice Address - Street 1:1501 E. BUSTAMANTE SUITE G
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041
Practice Address - Country:US
Practice Address - Phone:956-718-2020
Practice Address - Fax:956-718-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190441903Medicaid
TX190441903Medicaid