Healthcare Provider Details

I. General information

NPI: 1174356638
Provider Name (Legal Business Name): CHISOM VIVIAN OGBATA PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 N BRAESWOOD BLVD
HOUSTON TX
77074-7536
US

IV. Provider business mailing address

6711 SAN PABLO DR
HOUSTON TX
77083-2119
US

V. Phone/Fax

Practice location:
  • Phone: 713-778-5700
  • Fax:
Mailing address:
  • Phone: 832-497-7153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1398703
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: