Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 120104 | TX |
NPI | 1275182891 |
---|---|
Provider Name | Caleb Beraud |
First Address | Athens, TX 75751-3496 |
Second Address | Athens, TX 75751-3445 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2019 |
Last Update Date | 06/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
120104 | OT BOARD TEXAS (01) | TX |