Provider Demographics
NPI:1144239070
Name:OTTER, TINA (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:
Last Name:OTTER
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2956 I-45 NORTH
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77303
Mailing Address - Country:US
Mailing Address - Phone:936-441-4422
Mailing Address - Fax:936-441-4427
Practice Address - Street 1:2956 I-45 NORTH
Practice Address - Street 2:SUITE 500
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77303
Practice Address - Country:US
Practice Address - Phone:936-441-4422
Practice Address - Fax:936-441-4427
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1148649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00164SOtherMEDICARE PROVIDER GROUP N
TX8T0852OtherBLUE CROSS BLUE SHIELD
TX00164SOtherMEDICARE PROVIDER GROUP N