Provider Demographics
NPI:1114964079
Name:SERVANTES, VANESSA LEIGH (LPT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LEIGH
Last Name:SERVANTES
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:LEIGH
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4015 INTERSTATE 45 N
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-4901
Mailing Address - Country:US
Mailing Address - Phone:936-522-4731
Mailing Address - Fax:936-522-4737
Practice Address - Street 1:4015 INTERSTATE 45 N
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-4901
Practice Address - Country:US
Practice Address - Phone:936-522-4731
Practice Address - Fax:936-522-4737
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1115830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180685301Medicaid
TX8G6549Medicare PIN