Provider Demographics
NPI:1457852584
Name:OMOLE, OLUWASEYI REBECCA (PTA)
Entity Type:Individual
Prefix:MS
First Name:OLUWASEYI
Middle Name:REBECCA
Last Name:OMOLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13835 WESTHOLLOW PARK DR
Mailing Address - Street 2:#3602
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082
Mailing Address - Country:US
Mailing Address - Phone:832-883-6407
Mailing Address - Fax:
Practice Address - Street 1:13835 WESTHOLLOW PARK DR
Practice Address - Street 2:#3602
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082
Practice Address - Country:US
Practice Address - Phone:832-883-6407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-03-30
Deactivation Date:2018-02-23
Deactivation Code:
Reactivation Date:2018-03-30
Provider Licenses
StateLicense IDTaxonomies
TX2132497224Z00000X, 225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty