Provider Demographics
NPI:1164901260
Name:RIBEIRO, HARLEY DASSOW (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HARLEY
Middle Name:DASSOW
Last Name:RIBEIRO
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 1:1014 N NOLAN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-7935
Mailing Address - Country:US
Mailing Address - Phone:817-641-8617
Mailing Address - Fax:
Practice Address - Street 1:2010 W KATHERINE P RAINES RD STE 400
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7458
Practice Address - Country:US
Practice Address - Phone:817-357-8006
Practice Address - Fax:817-357-8620
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1309077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1309077OtherSTATE LICENSE NUMBER