Basic Information
| Provider Information | |||||||||
| NPI: | 1215149216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAACK | ||||||||
| FirstName: | AUBRIE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MOT, OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BILES | ||||||||
| OtherFirstName: | AUBRIE | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MOT, OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4114 PROVINCE DR | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750071638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722450942 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3800 HULEN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173353022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 02/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 111799 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 332789202 | 05 | TX | MEDICAID | 8TAB60 | 01 | TX | BCBS | OTHER |