Healthcare Provider Details

I. General information

NPI: 1831522341
Provider Name (Legal Business Name): BEAELISA SUZETTE DUCHAMP P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7909 PAT BOOKER RD
LIVE OAK TX
78233-2602
US

IV. Provider business mailing address

8627 CINNAMON CREEK DR SUITE 402
SAN ANTONIO TX
78240-1480
US

V. Phone/Fax

Practice location:
  • Phone: 210-653-2400
  • Fax: 210-653-2422
Mailing address:
  • Phone: 210-372-0211
  • Fax: 210-888-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1232143
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: