Provider Demographics
NPI:1689954919
Name:FIALLOS-MITCHELL, CHIARA TEVYAN (OT)
Entity Type:Individual
Prefix:
First Name:CHIARA
Middle Name:TEVYAN
Last Name:FIALLOS-MITCHELL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3576 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2053
Mailing Address - Country:US
Mailing Address - Phone:817-734-7682
Mailing Address - Fax:
Practice Address - Street 1:3576 W 4TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2053
Practice Address - Country:US
Practice Address - Phone:817-734-7682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist