Basic Information
| Provider Information | |||||||||
| NPI: | 1336645829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAL | ||||||||
| FirstName: | MIRTHALA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED.; LPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4709 CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785013796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564672717 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1901 S 24TH AVE | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785396533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9562897000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | 34021 | TX | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103T00000X | 34021 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.