=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912203407
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERITA NICOLE BAGBY MCCOLLUM LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2011
-----------------------------------------------------
Last Update Date | 02/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1830 SNAKE RIVER RD SUITE B
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77449-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-848-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 HOUGHTON RD #1711
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-3070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-848-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT111427
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------