Provider Demographics
NPI:1407312804
Name:GERAGHTY, DECLAN GERARD
Entity Type:Individual
Prefix:
First Name:DECLAN
Middle Name:GERARD
Last Name:GERAGHTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 W LYNN ST APT 208
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-4767
Mailing Address - Country:US
Mailing Address - Phone:847-565-9670
Mailing Address - Fax:
Practice Address - Street 1:3201 BEE CAVES RD STE 121
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-7060
Practice Address - Country:US
Practice Address - Phone:512-987-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13063812251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic