Basic Information
Provider Information | |||||||||
NPI: | 1992286637 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SELECT REHABILITATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 225 TENNISON RD APT 1102 | ||||||||
Address2: |   | ||||||||
City: | MT PLEASANT | ||||||||
State: | TX | ||||||||
PostalCode: | 754559350 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2600 COMPASS RD | ||||||||
Address2: |   | ||||||||
City: | GLENVIEW | ||||||||
State: | IL | ||||||||
PostalCode: | 600268001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8777873430 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2018 | ||||||||
LastUpdateDate: | 08/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HART | ||||||||
AuthorizedOfficialFirstName: | TAMMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 9035747183 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
ID | Type | State | Issuer | Description | 111216 | 01 | TX | OCCUPATIONAL THERAPIST | OTHER |