Basic Information
| Provider Information | |||||||||
| NPI: | 1356577639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBARRA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | GUADALUPE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROQUE | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | GUADALUPE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2335 E SAUNDERS ST | ||||||||
| Address2: | PLAZA 2 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780415434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567914800 | ||||||||
| FaxNumber: | 9567914422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2335 E SAUNDERS ST | ||||||||
| Address2: | PLAZA 2 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780415434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567914800 | ||||||||
| FaxNumber: | 9567914422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2009 | ||||||||
| LastUpdateDate: | 06/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 111289 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 111289 | 01 | TX | STATE LICENSE | OTHER |