Healthcare Provider Details

I. General information

NPI: 1407386014
Provider Name (Legal Business Name): WILMA BEVERLY WHITE OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ADAMS
GRANTS NM
87020
US

IV. Provider business mailing address

200 ADAMS AVE
GRANTS NM
87020-2812
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-4005
  • Fax:
Mailing address:
  • Phone: 505-876-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3405
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: