Provider Demographics
NPI:1114579265
Name:ALTORSHAN, NTUM AZA
Entity Type:Individual
Prefix:
First Name:NTUM
Middle Name:AZA
Last Name:ALTORSHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12330 GROVE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-2204
Mailing Address - Country:US
Mailing Address - Phone:281-725-3919
Mailing Address - Fax:
Practice Address - Street 1:12330 GROVE MEADOW DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2204
Practice Address - Country:US
Practice Address - Phone:281-725-3919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities