Provider Demographics
NPI:1760015150
Name:WISDOM, DOROTHY MARYMAY (PT,DPT)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:MARYMAY
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 MARINA BAY DR STE 105
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2882
Mailing Address - Country:US
Mailing Address - Phone:281-549-6404
Mailing Address - Fax:832-864-2580
Practice Address - Street 1:3023 MARINA BAY DR STE 105
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2882
Practice Address - Country:US
Practice Address - Phone:281-549-6404
Practice Address - Fax:832-864-2580
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1071686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1071686OtherPHYSICAL THERAPY LISCENSE