Provider Demographics
NPI:1487778346
Name:MIRAVITE, GAIL ANNETTE (OT)
Entity type:Individual
Prefix:MRS
First Name:GAIL
Middle Name:ANNETTE
Last Name:MIRAVITE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:GAIL
Other - Middle Name:ANNETTE
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:301 APACHE LDG
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-4303
Mailing Address - Country:US
Mailing Address - Phone:210-375-9850
Mailing Address - Fax:
Practice Address - Street 1:4214 E SOUTHCROSS BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3723
Practice Address - Country:US
Practice Address - Phone:210-590-7412
Practice Address - Fax:210-590-2343
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112013225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand