Provider Demographics
NPI:1346758893
Name:DEWBERRY, CHAUNDRA JA'NIECE
Entity Type:Individual
Prefix:
First Name:CHAUNDRA
Middle Name:JA'NIECE
Last Name:DEWBERRY
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 1:350 LAS COLINAS BLVD E APT 4077
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-5823
Mailing Address - Country:US
Mailing Address - Phone:682-472-1404
Mailing Address - Fax:
Practice Address - Street 1:404 RACQUET CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6408
Practice Address - Country:US
Practice Address - Phone:682-738-3056
Practice Address - Fax:682-738-3272
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2125483225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant