Provider Demographics
NPI:1255942470
Name:MUNOZ, BERTHA CARMEN (CMT)
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:CARMEN
Last Name:MUNOZ
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3562
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76099-3562
Mailing Address - Country:US
Mailing Address - Phone:817-888-1045
Mailing Address - Fax:
Practice Address - Street 1:1112 GLADE RD # 12
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-4227
Practice Address - Country:US
Practice Address - Phone:817-888-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120557225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty