Provider Demographics
NPI:1851552228
Name:THERAPEUTIC LIFESTYLE
Entity Type:Organization
Organization Name:THERAPEUTIC LIFESTYLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.T/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:DONNELLON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:956-400-5877
Mailing Address - Street 1:904 LAS BRISAS DR
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78574-0425
Mailing Address - Country:US
Mailing Address - Phone:956-400-5877
Mailing Address - Fax:956-424-3535
Practice Address - Street 1:904 LAS BRISAS DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78574-0425
Practice Address - Country:US
Practice Address - Phone:956-400-5877
Practice Address - Fax:956-424-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1118529225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty