=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164595559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARBARA ANN DIBALA RMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2308 HIGHWAY 36 S
-----------------------------------------------------
City | SEALY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77474-4223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-885-7484
-----------------------------------------------------
Fax | 979-885-7485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 513
-----------------------------------------------------
City | WALLIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77485-0513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-478-7221
-----------------------------------------------------
Fax | 979-885-7485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MTO43649
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------