Provider Demographics
NPI:1124034343
Name:PROFESSIONAL THERAPY SERVICES
Entity Type:Organization
Organization Name:PROFESSIONAL THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DERMONT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-654-7428
Mailing Address - Street 1:14220 NORTHBROOK
Mailing Address - Street 2:STE 700
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232
Mailing Address - Country:US
Mailing Address - Phone:210-822-8807
Mailing Address - Fax:210-822-8863
Practice Address - Street 1:8800 VILLAGE DR
Practice Address - Street 2:STE 101
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-654-7428
Practice Address - Fax:210-654-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX636700002225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU46FOtherBLUE CROSS BLUE SHIELD
TX0814931-01Medicaid
TXU46FOtherBLUE CROSS BLUE SHIELD