Basic Information
| Provider Information | |||||||||
| NPI: | 1356450001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITLE | ||||||||
| FirstName: | MIDGE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSS | ||||||||
| OtherFirstName: | MIDGE | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2906 BIG BEN LN | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4695831793 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1410 14TH ST | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750746302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724240148 | ||||||||
| FaxNumber: | 9724225275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 108241 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8T6111 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |