Provider Demographics
NPI:1225280555
Name:SELF, LINDY
Entity Type:Individual
Prefix:
First Name:LINDY
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-7109
Mailing Address - Country:US
Mailing Address - Phone:903-824-1259
Mailing Address - Fax:
Practice Address - Street 1:17521 US HIGHWAY 69 S
Practice Address - Street 2:SUITE 120
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5376
Practice Address - Country:US
Practice Address - Phone:903-839-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2064169225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant