Healthcare Provider Details

I. General information

NPI: 1780018556
Provider Name (Legal Business Name): NICOLE RHEANNE HALLUMS OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8103 NORTH HOLW
SAN ANTONIO TX
78240-2387
US

IV. Provider business mailing address

8103 NORTH HOLW
SAN ANTONIO TX
78240-2387
US

V. Phone/Fax

Practice location:
  • Phone: 210-558-9001
  • Fax: 210-558-9010
Mailing address:
  • Phone: 210-558-9001
  • Fax: 210-558-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number209942
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: