Provider Demographics
NPI:1417352857
Name:WOLLITZ, BEVERLY (PTA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:WOLLITZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 THOMPSON CIR
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655-9682
Mailing Address - Country:US
Mailing Address - Phone:254-315-8379
Mailing Address - Fax:
Practice Address - Street 1:124 THOMPSON CIR
Practice Address - Street 2:
Practice Address - City:LORENA
Practice Address - State:TX
Practice Address - Zip Code:76655-9682
Practice Address - Country:US
Practice Address - Phone:254-315-8379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2049848225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant