Provider Demographics
NPI:1902168818
Name:MINK, THEODORE JOHN (OTR)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:MINK
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 W HIGHWAY 71
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-8602
Mailing Address - Country:US
Mailing Address - Phone:830-201-7100
Mailing Address - Fax:830-201-7143
Practice Address - Street 1:810 W HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-8602
Practice Address - Country:US
Practice Address - Phone:830-201-7100
Practice Address - Fax:830-201-7143
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6139225X00000X
TX117753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117753OtherOT LISCENSE