Provider Demographics
NPI:1548580608
Name:BERTRAND, EVA
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:BERTRAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ROAD TO SIX FLAGS W STE 105
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2615
Mailing Address - Country:US
Mailing Address - Phone:817-462-8111
Mailing Address - Fax:817-462-8110
Practice Address - Street 1:801 ROAD TO SIX FLAGS W STE 105
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2615
Practice Address - Country:US
Practice Address - Phone:817-462-8111
Practice Address - Fax:817-462-8110
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1094589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283647002Medicaid
TXTXB113718OtherMEDICARE PTAN