=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629411400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP CLARK STOLTS OTR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2013
-----------------------------------------------------
Last Update Date | 04/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 LORENALY DR STE D
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78526-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-350-6696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2205 WOOLAM RD
-----------------------------------------------------
City | SAN BENITO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78586-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-536-7589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 114719
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------