MEDICARE: GRACE EUBANKS OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	103221	TX

General Provider Information

NPI Number	:	1033114913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE EUBANKS OT

Provider Business Mailing Address
First Line	:	PO BOX 875
Second Line	:
City	:	LAKE DALLAS
State	:	TX
Zip	:	75065-0875
Country	:	US
Telephone Number	:	214-629-6635
Fax Number	:	469-844-4346

Provider Business Practice Location Address
First Line	:	3119 BERKSHIRE LN
Second Line	:
City	:	CORINTH
State	:	TX
Zip	:	76210-1726
Country	:	US
Telephone Number	:	214-629-6635
Fax Number	:	469-844-4346

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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