Provider Demographics
NPI:1407889694
Name:LOGOPEDIA THERAPY CLINIC, INC.
Entity type:Organization
Organization Name:LOGOPEDIA THERAPY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DALIA
Authorized Official - Middle Name:I
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC,SLP
Authorized Official - Phone:956-380-3400
Mailing Address - Street 1:3409 W STATE HIGHWAY 107
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-2802
Mailing Address - Country:US
Mailing Address - Phone:956-380-3400
Mailing Address - Fax:956-380-3448
Practice Address - Street 1:3409 W STATE HIGHWAY 107
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-2802
Practice Address - Country:US
Practice Address - Phone:956-380-3400
Practice Address - Fax:956-380-3448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10600362251P0200X
TX111342225XP0200X
TX102044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1825424-02Medicaid
TX1825424-02Medicaid