Provider Demographics
NPI:1457945065
Name:PANGANIBAN, CAMILLE (COTA)
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:
Last Name:PANGANIBAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19221 I-45 S.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385
Mailing Address - Country:US
Mailing Address - Phone:936-585-5019
Mailing Address - Fax:936-585-4416
Practice Address - Street 1:19221 I-45 S.
Practice Address - Street 2:SUITE 120
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385
Practice Address - Country:US
Practice Address - Phone:936-585-5019
Practice Address - Fax:936-585-4416
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216470224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant