Provider Demographics
NPI:1043816788
Name:MENGISTE, SAMRAWIT SISAY (PTA)
Entity Type:Individual
Prefix:
First Name:SAMRAWIT
Middle Name:SISAY
Last Name:MENGISTE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 RED WREN CIR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-7108
Mailing Address - Country:US
Mailing Address - Phone:773-751-9848
Mailing Address - Fax:
Practice Address - Street 1:2010 RED WREN CIR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-7108
Practice Address - Country:US
Practice Address - Phone:773-751-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2157658225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant