=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033114913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE EUBANKS OT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3119 BERKSHIRE LN
-----------------------------------------------------
City | CORINTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-629-6635
-----------------------------------------------------
Fax | 469-844-4346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 875
-----------------------------------------------------
City | LAKE DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75065-0875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-629-6635
-----------------------------------------------------
Fax | 469-844-4346
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 103221
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------