Provider Demographics
NPI:1215149216
Name:BAACK, AUBRIE MICHELLE (MOT, OTR)
Entity type:Individual
Prefix:
First Name:AUBRIE
Middle Name:MICHELLE
Last Name:BAACK
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:AUBRIE
Other - Middle Name:MICHELLE
Other - Last Name:BILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR
Mailing Address - Street 1:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-335-4022
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:817-335-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111799225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8TAB60OtherBCBS
TX332789202Medicaid