Provider Demographics
NPI:1245960657
Name:SCOVILLE, CORA MERCEDES
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:MERCEDES
Last Name:SCOVILLE
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 1:1100 LAKE CAROLYN PKWY APT 3011
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-4714
Mailing Address - Country:US
Mailing Address - Phone:402-213-3020
Mailing Address - Fax:
Practice Address - Street 1:15601 DALLAS PKWY STE 125
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3353
Practice Address - Country:US
Practice Address - Phone:214-292-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty