Basic Information
| Provider Information | |||||||||
| NPI: | 1861883605 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIGH | ||||||||
| FirstName: | TALICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2603 | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761132603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3840 HULEN ST | ||||||||
| Address2: | HTN, CLIENT ACCOUNTING | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761077277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175694300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2015 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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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 | 116667 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 342813801 | 05 | TX | MEDICAID | 8TAE49 | 01 | TX | BCBS | OTHER |