MEDICARE: MISS TINA OTTER PHYSICAL THERAPIST

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	225100000X	Physical Therapist	1148649	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00164S	OTHER	TX	MEDICARE PROVIDER GROUP N

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	8T0852	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1144239070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TINA OTTER PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	2956 I-45 NORTH
Second Line	:	SUITE 500
City	:	CONROE
State	:	TX
Zip	:	77303
Country	:	US
Telephone Number	:	936-441-4422
Fax Number	:	936-441-4427

Provider Business Practice Location Address
First Line	:	2956 I-45 NORTH
Second Line	:	SUITE 500
City	:	CONROE
State	:	TX
Zip	:	77303
Country	:	US
Telephone Number	:	936-441-4422
Fax Number	:	936-441-4427

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

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	09/08/2020

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