1174631618 NPI number — BETH ANN GIST OT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174631618 NPI number — BETH ANN GIST OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIST
Provider First Name:
BETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIST
Provider Other First Name:
ELIZBETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BETH CRABB
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174631618
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
503 PARK PLACE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76504-2188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-913-4848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1349 EMPIRE CENTRAL DR STE 516
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75247-4066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-291-8500
Provider Business Practice Location Address Fax Number:
214-265-0420
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  109053 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BCBS . This is a "8T6191" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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