Healthcare Provider Details

I. General information

NPI: 1104176155
Provider Name (Legal Business Name): NORTH TEXAS REHABILITATION CENTER INC. ECI PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MIDWESTERN PKWY
WICHITA FALLS TX
76302-2211
US

IV. Provider business mailing address

1005 MIDWESTERN PKWY
WICHITA FALLS TX
76302-2211
US

V. Phone/Fax

Practice location:
  • Phone: 940-322-0771
  • Fax: 940-766-4943
Mailing address:
  • Phone: 940-322-0771
  • Fax: 940-766-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number508250000
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number604700000
License Number StateTX

VIII. Authorized Official

Name: SAUNDRA THOMPSON
Title or Position: CREDENTIALING
Credential:
Phone: 940-322-0771