Basic Information
| Provider Information | |||||||||
| NPI: | 1285030049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUAREZ | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOUKOUENDJI | ||||||||
| OtherFirstName: | DENISE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 620 N ALLEGHANEY AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323328244 | ||||||||
| FaxNumber: | 4325807428 | ||||||||
| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173353022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2014 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 114764 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 114764 | 01 | TX | STATE LICENSE | OTHER |