Provider Demographics
NPI:1104176155
Name:NORTH TEXAS REHABILITATION CENTER INC. ECI PROGRAM
Entity type:Organization
Organization Name:NORTH TEXAS REHABILITATION CENTER INC. ECI PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SAUNDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-322-0771
Mailing Address - Street 1:1005 MIDWESTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-2211
Mailing Address - Country:US
Mailing Address - Phone:940-322-0771
Mailing Address - Fax:940-766-4943
Practice Address - Street 1:1005 MIDWESTERN PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2211
Practice Address - Country:US
Practice Address - Phone:940-322-0771
Practice Address - Fax:940-766-4943
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH TEXAS REHABILITATION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP2500X, 104100000X, 235Z00000X
TX508250000225X00000X
TX604700000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111408402Medicaid
TX456554Medicare PIN