Provider Demographics
NPI:1205199684
Name:MEEHAN SPORTS THERAPY & PEDIATRICS PLLC
Entity Type:Organization
Organization Name:MEEHAN SPORTS THERAPY & PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT,PCS
Authorized Official - Phone:817-239-4395
Mailing Address - Street 1:100 W SOUTHLAKE BLVD
Mailing Address - Street 2:STE 420
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6100
Mailing Address - Country:US
Mailing Address - Phone:817-239-4395
Mailing Address - Fax:817-421-4671
Practice Address - Street 1:100 W SOUTHLAKE BLVD
Practice Address - Street 2:STE 420
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6100
Practice Address - Country:US
Practice Address - Phone:817-239-4395
Practice Address - Fax:817-421-4671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116453261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy