Healthcare Provider Details

I. General information

NPI: 1083276067
Provider Name (Legal Business Name): CHRISTINE DANIELLE FATA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE DANIELLE FATA OTR/L

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY DR
FORT WORTH TX
76107-1360
US

IV. Provider business mailing address

3017 PONDER PATH
KELLER TX
76248-1201
US

V. Phone/Fax

Practice location:
  • Phone: 817-814-2000
  • Fax:
Mailing address:
  • Phone: 817-891-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number119915
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: