Provider Demographics
NPI:1053086959
Name:HERRON, ITALI (PTA)
Entity Type:Individual
Prefix:
First Name:ITALI
Middle Name:
Last Name:HERRON
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 1:205 PEGGY DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-4459
Mailing Address - Country:US
Mailing Address - Phone:254-661-3917
Mailing Address - Fax:
Practice Address - Street 1:3415 WILLIAMS DR STE 145
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2886
Practice Address - Country:US
Practice Address - Phone:512-887-4544
Practice Address - Fax:512-887-4542
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2161087225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant