Basic Information
| Provider Information | |||||||||
| NPI: | 1336669720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACCALLUM | ||||||||
| FirstName: | ETHEL | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 PELICAN ST | ||||||||
| Address2: | |||||||||
| City: | MAGNOLIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773553421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172928787 | ||||||||
| FaxNumber: | 8177896849 | ||||||||
| Practice Location | |||||||||
| Address1: | 14515 BRIARHILLS PKWY STE 208 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770771034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328502733 | ||||||||
| FaxNumber: | 7135752031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 108431 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.