Provider Demographics
NPI:1205020187
Name:MICHAEL, SCOTT (PTA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:MICHAEL
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 1:613 S AVE D
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:TX
Mailing Address - Zip Code:79745-4822
Mailing Address - Country:US
Mailing Address - Phone:432-586-2072
Mailing Address - Fax:
Practice Address - Street 1:411 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2005
Practice Address - Country:US
Practice Address - Phone:903-885-1483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2149-9225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant