Basic Information
Provider Information | |||||||||
NPI: | 1760847834 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TEXAS PHYSICAL THERAPY SPECIALISTS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17325 BELL NORTH DR | ||||||||
Address2: | SUITE 2-B | ||||||||
City: | SCHERTZ | ||||||||
State: | TX | ||||||||
PostalCode: | 781543368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8885904002 | ||||||||
FaxNumber: | 2105904585 | ||||||||
Practice Location | |||||||||
Address1: | 2902 GOLIAD RD | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782233958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8885904002 | ||||||||
FaxNumber: | 2105904585 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2015 | ||||||||
LastUpdateDate: | 12/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURRELL | ||||||||
AuthorizedOfficialFirstName: | SHYLA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 8885904002 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 170506301 | 05 | TX |   | MEDICAID |