Provider Demographics
NPI:1477879112
Name:CANTRELL, RENE K (PTA)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:K
Last Name:CANTRELL
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 1:1319 SUMMIT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-4433
Mailing Address - Country:US
Mailing Address - Phone:817-339-3900
Mailing Address - Fax:817-339-3983
Practice Address - Street 1:1319 SUMMIT AVE STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-4433
Practice Address - Country:US
Practice Address - Phone:817-339-3900
Practice Address - Fax:817-339-3983
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2015442225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant