Provider Demographics
NPI:1487954061
Name:CAZALLA, JOSE (MA)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:CAZALLA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2049 S TRIVIZ DR APT E17
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5895
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 S MAIN ST STE 249
Practice Address - Street 2:LAS CRUCES PUBLIC SCHOOLS
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-805-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-4812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist