Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | 107939 | TX |
NPI | 1639122674 |
---|---|
Provider Name | Mrs. Melissa M Fortenberry |
First Address | Houston, TX 77096-5030 |
Second Address | Houston, TX 77027-7313 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2006 |
Last Update Date | 28/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1016955 | BLUE LINK NUMBER (01) | TX |
107939 | LISCENSE (01) | TX |
P00357763 | RAILROAD MEDICARE PROVIDE (01) | TX |