Provider Demographics
NPI:1760814164
Name:SIMON, JUSTIN CODY (DPT, OCS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:CODY
Last Name:SIMON
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E WILLIAM CANNON DR STE 225
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-6644
Mailing Address - Country:US
Mailing Address - Phone:512-270-2060
Mailing Address - Fax:
Practice Address - Street 1:4100 EVERETT DR STE 130
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6332
Practice Address - Country:US
Practice Address - Phone:512-738-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1234515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist