Basic Information
| Provider Information | |||||||||
| NPI: | 1306326954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 RENFERT WAY, SUITES 120 AND 300 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787585444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128738900 | ||||||||
| FaxNumber: | 5128348676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2018 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1307398 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 406229102 | 05 | TX | MEDICAID | 406229101 | 05 | TX | MEDICAID |