Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1198953 | TX |
N | 2251G0304X | Physical Therapist - Geriatrics | 1198953 | TX |
N | 2251N0400X | Physical Therapist - Neurology | 1198953 | TX |
NPI | 1336441823 |
---|---|
Provider Name | Myla Quiben |
First Address | Fort Worth, TX 76199-0335 |
Second Address | Fort Worth, TX 76107-2553 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/12/2010 |
Last Update Date | 11/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
343396301 | (05) | TX |
8TAC71 | BCBS (01) | TX |