Provider Demographics
NPI:1235856238
Name:JIRANORRAWAT, SUTTIVIT (PT)
Entity Type:Individual
Prefix:
First Name:SUTTIVIT
Middle Name:
Last Name:JIRANORRAWAT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 STONEWOOD DR APT 2814
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-5298
Mailing Address - Country:US
Mailing Address - Phone:864-205-5955
Mailing Address - Fax:
Practice Address - Street 1:5550 HARVEST HILL RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1684
Practice Address - Country:US
Practice Address - Phone:972-665-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1364627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist