Healthcare Provider Details

I. General information

NPI: 1568156453
Provider Name (Legal Business Name): KIAE WAITE-GOLLAB MT-BC, NMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8310 EWING HALSELL DR
SAN ANTONIO TX
78229-3715
US

IV. Provider business mailing address

6418 ECKHERT RD APT 7205
SAN ANTONIO TX
78240-3153
US

V. Phone/Fax

Practice location:
  • Phone: 210-616-0885
  • Fax:
Mailing address:
  • Phone: 361-816-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number13280
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: