Basic Information
| Provider Information | |||||||||
| NPI: | 1942879762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | VEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 N US HIGHWAY 83 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788391615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567226221 | ||||||||
| FaxNumber: | 9567226275 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 N US HIGHWAY 83 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788391615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567226221 | ||||||||
| FaxNumber: | 9567226275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2021 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2355S0801X | 41940 | TX | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
ID Information
| ID | Type | State | Issuer | Description | 41940 | 01 | TX | SLPA | OTHER |