Provider Demographics
NPI:1679328876
Name:LEDEZMA, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:LEDEZMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 SAN PATRICIO ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5953
Mailing Address - Country:US
Mailing Address - Phone:210-995-6858
Mailing Address - Fax:
Practice Address - Street 1:119 SW LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2101
Practice Address - Country:US
Practice Address - Phone:210-745-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT24341315106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician