Provider Demographics
NPI:1114568359
Name:TYDLACKA, THOMAS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:TYDLACKA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 BONNIE LN
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-7377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3023 MARINA BAY DR STE 105
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2882
Practice Address - Country:US
Practice Address - Phone:281-549-6404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic