Provider Demographics
NPI:1336693589
Name:RANDLE, TAYLOR WADE-WHITING (DPT, FAAOMPT, CSCS)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:WADE-WHITING
Last Name:RANDLE
Suffix:
Gender:M
Credentials:DPT, FAAOMPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 GEMINI ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2806
Mailing Address - Country:US
Mailing Address - Phone:281-335-1111
Mailing Address - Fax:281-286-9250
Practice Address - Street 1:1045 GEMINI ST STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2806
Practice Address - Country:US
Practice Address - Phone:281-335-1111
Practice Address - Fax:281-286-9250
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1278318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist