Basic Information
| Provider Information | |||||||||
| NPI: | 1437269131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLWATER | ||||||||
| FirstName: | JOAN | ||||||||
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| Credential: | CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10555 CULEBRA RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782513666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108886042 | ||||||||
| FaxNumber: | 2108886045 | ||||||||
| Practice Location | |||||||||
| Address1: | 10555 CULEBRA RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782513666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108886042 | ||||||||
| FaxNumber: | 2108886045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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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 | 225100000X | 103597 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | 103597 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 103597 | 01 | TX | LICENSE # | OTHER |