Basic Information
| Provider Information | |||||||||
| NPI: | 1306041025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOKE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | SLPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2335 E SAUNDERS ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780415434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567914800 | ||||||||
| FaxNumber: | 9567914422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2335 E SAUNDERS ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780415434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567914800 | ||||||||
| FaxNumber: | 9567914422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 34024 | TX | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
| ID | Type | State | Issuer | Description | 34024 | 01 | TX | STATE LICENSE | OTHER |