Provider Demographics
NPI:1679681290
Name:INNOVATIVE THERAPY P.C.
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:956-994-1700
Mailing Address - Street 1:4101 MCEWEN RD STE 465
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5129
Mailing Address - Country:US
Mailing Address - Phone:956-994-1700
Mailing Address - Fax:888-816-3627
Practice Address - Street 1:4101 MCEWEN RD STE 465
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244
Practice Address - Country:US
Practice Address - Phone:956-994-1700
Practice Address - Fax:888-816-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX622860000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87740901Medicaid
=========OtherFEDERAL TAX ID NUMBER
TX00993EMedicare ID - Type Unspecified