Healthcare Provider Details

I. General information

NPI: 1346901485
Provider Name (Legal Business Name): NIDIA DELCARMEN THIES COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11110 TOM ADAMS DR
AUSTIN TX
78753-3354
US

IV. Provider business mailing address

2917 ALLISON DR
AUSTIN TX
78741-7314
US

V. Phone/Fax

Practice location:
  • Phone: 512-836-1515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number215933
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: