Provider Demographics
NPI:1063622314
Name:OUR LADY OF THE LAKE UNIVERSITY
Entity type:Organization
Organization Name:OUR LADY OF THE LAKE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:210-434-6711
Mailing Address - Street 1:411 SW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-4617
Mailing Address - Country:US
Mailing Address - Phone:210-434-6711
Mailing Address - Fax:210-434-9360
Practice Address - Street 1:411 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-4617
Practice Address - Country:US
Practice Address - Phone:210-434-6711
Practice Address - Fax:210-434-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty