Basic Information
| Provider Information | |||||||||
| NPI: | 1588894810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DREEBEN IRIMIA | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PT,PHD,MPT | ||||||||
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| OtherLastName: | DREEBEN | ||||||||
| OtherFirstName: | OLGA | ||||||||
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| OtherCredential: | PT,PHD,MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 99335 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177352000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 855 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761072553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177352000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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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 | 1187730 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 847T29 | 01 | TX | BCBS | OTHER | 216821301 | 05 | TX | MEDICAID |