Provider Demographics
NPI:1811415516
Name:MACK, BRITTANY DANIELLE (PTA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:DANIELLE
Last Name:MACK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 RACQUET CLUB BLVD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022
Mailing Address - Country:US
Mailing Address - Phone:682-738-3056
Mailing Address - Fax:
Practice Address - Street 1:404 RACQUET CLUB BLVD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6408
Practice Address - Country:US
Practice Address - Phone:682-738-3262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2127229225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant