Provider Demographics
NPI:1831649433
Name:PETREE, JOE (PTA)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:PETREE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CISCO
Mailing Address - State:TX
Mailing Address - Zip Code:76437-3023
Mailing Address - Country:US
Mailing Address - Phone:254-631-7503
Mailing Address - Fax:
Practice Address - Street 1:200 W 8TH ST
Practice Address - Street 2:
Practice Address - City:CISCO
Practice Address - State:TX
Practice Address - Zip Code:76437-3023
Practice Address - Country:US
Practice Address - Phone:254-631-7503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2114207225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant