Basic Information
| Provider Information | |||||||||
| NPI: | 1902168818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINK | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 W HIGHWAY 71 | ||||||||
| Address2: | |||||||||
| City: | MARBLE FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786548602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302017100 | ||||||||
| FaxNumber: | 8302017143 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 W HIGHWAY 71 | ||||||||
| Address2: | |||||||||
| City: | MARBLE FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786548602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302017100 | ||||||||
| FaxNumber: | 8302017143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6139 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 117753 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 117753 | 01 | TX | OT LISCENSE | OTHER |