Basic Information
| Provider Information | |||||||||
| NPI: | 1811644024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALVAN | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 HARTFORD ST | ||||||||
| Address2: | |||||||||
| City: | ABILENE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 796054603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3257933400 | ||||||||
| FaxNumber: | 3257933587 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANGELO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 769045129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252236300 | ||||||||
| FaxNumber: | 3257933587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2022 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 122536 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 122536 | 01 | TX | COMMERCIAL | OTHER | 122536 | 05 | TX | MEDICAID |