MEDICARE: METTE JANE ADAMS BLOCKHAN O.T.

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	174400000X	Specialist	105121	TX

General Provider Information

NPI Number	:	1033152905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	METTE JANE ADAMS BLOCKHAN O.T.

Provider Business Mailing Address
First Line	:	6256 GLENVIEW DR
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-9255
Country	:	US
Telephone Number	:	817-428-4475
Fax Number	:

Provider Business Practice Location Address
First Line	:	5601 BRIDGE ST
Second Line	:	SUITE 500
City	:	FORT WORTH
State	:	TX
Zip	:	76112-2384
Country	:	US
Telephone Number	:	817-457-9850
Fax Number	:	817-457-9865

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/08/2007

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