=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427640226
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA GENESYS GAMEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2021
-----------------------------------------------------
Last Update Date | 02/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 E FERN AVE STE 103
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-1523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-627-0902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 982 WASHINGTON AVE
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-3422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-960-5525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 216516
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------