Provider Demographics
NPI:1548143951
Name:DIESTO, CAMRYN JORDAN
Entity type:Individual
Prefix:
First Name:CAMRYN
Middle Name:JORDAN
Last Name:DIESTO
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 1:2625 ANITA DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-2703
Mailing Address - Country:US
Mailing Address - Phone:214-621-8824
Mailing Address - Fax:
Practice Address - Street 1:2625 ANITA DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-2703
Practice Address - Country:US
Practice Address - Phone:972-490-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-31
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122811235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist