MEDICARE: CHIARA TEVYAN FIALLOS-MITCHELL 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	112161	TX

General Provider Information

NPI Number	:	1689954919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHIARA TEVYAN FIALLOS-MITCHELL OT

Provider Business Mailing Address
First Line	:	3576 W 4TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2053
Country	:	US
Telephone Number	:	817-734-7682
Fax Number	:

Provider Business Practice Location Address
First Line	:	3576 W 4TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2053
Country	:	US
Telephone Number	:	817-734-7682
Fax Number	:

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

Provider Enumeration Date	:	08/18/2011
Last Update Date	:	08/18/2011

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