Provider Demographics
NPI:1740422575
Name:EAST TEXAS PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:EAST TEXAS PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PTA
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:214-336-2248
Mailing Address - Street 1:1738 VZCR 3103
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:75117-5020
Mailing Address - Country:US
Mailing Address - Phone:214-336-2248
Mailing Address - Fax:972-534-1881
Practice Address - Street 1:1738 VZCR 3103
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:TX
Practice Address - Zip Code:75117-5020
Practice Address - Country:US
Practice Address - Phone:214-336-2248
Practice Address - Fax:972-534-1881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty