Provider Demographics
NPI:1356484349
Name:TUNGATE, VALISA A (LPT)
Entity Type:Individual
Prefix:
First Name:VALISA
Middle Name:A
Last Name:TUNGATE
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99283
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-1383
Mailing Address - Country:US
Mailing Address - Phone:682-885-6294
Mailing Address - Fax:682-885-1135
Practice Address - Street 1:1101 W VICKERY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:682-885-6294
Practice Address - Fax:682-885-1135
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11412732251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180675401Medicaid
TX8T5425OtherBCBS