Provider Demographics
NPI:1265867063
Name:MANKERIOUS, BASEM (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BASEM
Middle Name:
Last Name:MANKERIOUS
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 1:6006 VANCIL DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-0940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3107 W CAMP WISDOM RD
Practice Address - Street 2:SUITE 131
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2643
Practice Address - Country:US
Practice Address - Phone:214-339-4533
Practice Address - Fax:214-339-4738
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1232378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist