Healthcare Provider Details

I. General information

NPI: 1124352554
Provider Name (Legal Business Name): LYDIA HERNANDEZ OTR, MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 10/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10515 GULFDALE
SAN ANTONIO TX
78216-3667
US

IV. Provider business mailing address

259 MENLO BLVD
SAN ANTONIO TX
78223-1937
US

V. Phone/Fax

Practice location:
  • Phone: 210-340-2627
  • Fax: 210-340-6437
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number113059
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: