Provider Demographics
NPI:1053504738
Name:REZA, ANN MARIE (MSCCCSLP)
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:MARIE
Last Name:REZA
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:LA JOYA
Mailing Address - State:TX
Mailing Address - Zip Code:78560-0208
Mailing Address - Country:US
Mailing Address - Phone:956-583-5000
Mailing Address - Fax:956-583-5024
Practice Address - Street 1:836 E EXPRESSWAY 83
Practice Address - Street 2:
Practice Address - City:LA JOYA
Practice Address - State:TX
Practice Address - Zip Code:78560-4178
Practice Address - Country:US
Practice Address - Phone:956-583-5000
Practice Address - Fax:956-583-5024
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-24
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14000931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187198001Medicaid