Basic Information
| Provider Information | |||||||||
| NPI: | 1992381701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLOCK | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | MAIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARTYM | ||||||||
| OtherFirstName: | CANDACE | ||||||||
| OtherMiddleName: | MAIA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2520 BLUMBERG PARK | ||||||||
| Address2: | |||||||||
| City: | SEGUIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781553002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178255008 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DR BLDG 3634 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109166100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2160566 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.