Provider Demographics
NPI:1508499740
Name:THAI, JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:THAI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 HIGHWAY 71 W STE 100
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-4166
Mailing Address - Country:US
Mailing Address - Phone:512-321-9659
Mailing Address - Fax:
Practice Address - Street 1:623 HIGHWAY 71 W STE 100
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4166
Practice Address - Country:US
Practice Address - Phone:512-321-9659
Practice Address - Fax:512-321-1226
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1328851225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist