Provider Demographics
NPI:1366929341
Name:FACHA, MARA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:FACHA
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:RINCON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9514 CONSOLE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2042
Mailing Address - Country:US
Mailing Address - Phone:210-448-9111
Mailing Address - Fax:210-340-1259
Practice Address - Street 1:9514 CONSOLE DR STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2042
Practice Address - Country:US
Practice Address - Phone:210-448-9111
Practice Address - Fax:210-340-1259
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118276235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173913801Medicaid