Provider Demographics
NPI:1073756144
Name:SHED, ADAM (PTA)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:SHED
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 N BELT LINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-1784
Mailing Address - Country:US
Mailing Address - Phone:972-289-0691
Mailing Address - Fax:
Practice Address - Street 1:1313 N BELT LINE RD STE 102
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-1784
Practice Address - Country:US
Practice Address - Phone:972-289-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2067940225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant