Basic Information
| Provider Information | |||||||||
| NPI: | 1912170770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHMOUD | ||||||||
| FirstName: | DERAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17911 HYDE COVE CT | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774075010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133840525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12777 BEECHNUT ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770723820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818798040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2008 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 113970 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 113970 | 01 | TX | TEXAS OCCUPATIONAL THERAPY LICENSE | OTHER |