Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 100823 | TX |
NPI | 1013498526 |
---|---|
Provider Name | Joan Krystyniak-Collins |
First Address | Cresson, TX 76035-4505 |
Second Address | Glen Rose, TX 76043-4937 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2018 |
Last Update Date | 22/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100823 | OT LICENSE (01) | TX |