Provider Demographics
NPI:1598968505
Name:FORT WORTH PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:FORT WORTH PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-304-4786
Mailing Address - Street 1:7277 HAWKINS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3921
Mailing Address - Country:US
Mailing Address - Phone:817-423-5611
Mailing Address - Fax:817-423-5577
Practice Address - Street 1:7277 HAWKINS VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3921
Practice Address - Country:US
Practice Address - Phone:817-423-5611
Practice Address - Fax:817-423-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1117091225100000X
TX109622225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196088201Medicaid
TX196088201Medicaid
TX6238700001Medicare NSC