Provider Demographics
NPI:1245739499
Name:FULLER, SABRINA (PT)
Entity Type:Individual
Prefix:
First Name:SABRINA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SABRINA
Other - Middle Name:
Other - Last Name:EICKHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7601 GATEWAY BLVD APT 821
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2757
Mailing Address - Country:US
Mailing Address - Phone:210-838-0922
Mailing Address - Fax:
Practice Address - Street 1:7909 PAT BOOKER RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2602
Practice Address - Country:US
Practice Address - Phone:210-653-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1300856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist