Basic Information
Provider Information | |||||||||
NPI: | 1265590715 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARZA | ||||||||
FirstName: | EVANGELINA | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DURAN | ||||||||
OtherFirstName: | EVANGELINA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTR | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1900 S JACKSON RD STE 3 | ||||||||
Address2: |   | ||||||||
City: | MCALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 785031589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9566304400 | ||||||||
FaxNumber: | 9566304447 | ||||||||
Practice Location | |||||||||
Address1: | 1900 S JACKSON RD STE 3 | ||||||||
Address2: |   | ||||||||
City: | MCALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 785031589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9566304400 | ||||||||
FaxNumber: | 9566304447 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2006 | ||||||||
LastUpdateDate: | 02/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 111166 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 143404501 | 05 | TX |   | MEDICAID | 742965954 | 01 | TX | FACILITY TAX ID NO. | OTHER |