MEDICARE: NICOLE RHEANNE HALLUMS OTA

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	224Z00000X	Occupational Therapy Assistant	209942	TX

General Provider Information

NPI Number	:	1780018556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE RHEANNE HALLUMS OTA

Provider Business Mailing Address
First Line	:	8103 NORTH HOLW
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2387
Country	:	US
Telephone Number	:	210-558-9001
Fax Number	:	210-558-9010

Provider Business Practice Location Address
First Line	:	8103 NORTH HOLW
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2387
Country	:	US
Telephone Number	:	210-558-9001
Fax Number	:	210-558-9010

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

Provider Enumeration Date	:	08/28/2013
Last Update Date	:	08/28/2013

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