Provider Demographics
NPI:1316554595
Name:COSTILLA, BRANT EDWARD (PTA)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:EDWARD
Last Name:COSTILLA
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 1:1814 WOOD DUCK CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-9427
Mailing Address - Country:US
Mailing Address - Phone:469-222-7619
Mailing Address - Fax:
Practice Address - Street 1:2112 FORUM PKWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6028
Practice Address - Country:US
Practice Address - Phone:817-799-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2131372225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant