Provider Demographics
NPI:1639322324
Name:RAETZ, TAYLOR RYAN (PT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RYAN
Last Name:RAETZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 STATE HIGHWAY 174
Mailing Address - Street 2:
Mailing Address - City:KOPPERL
Mailing Address - State:TX
Mailing Address - Zip Code:76652-4669
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 FM 1960 RD W # 340
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3402
Practice Address - Country:US
Practice Address - Phone:281-440-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1174806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist