Provider Demographics
NPI:1689168569
Name:NAKHLA, MIRA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:
Last Name:NAKHLA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 BABCOCK RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4412
Mailing Address - Country:US
Mailing Address - Phone:210-614-3911
Mailing Address - Fax:210-625-3162
Practice Address - Street 1:2203 BABCOCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4412
Practice Address - Country:US
Practice Address - Phone:210-614-3911
Practice Address - Fax:210-625-3162
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18-57898106S00000X
TX122815225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty