Provider Demographics
NPI:1134158371
Name:COLLEYVILLE PHYSICAL THERAPY AND SPORTS REHAB, PC
Entity type:Organization
Organization Name:COLLEYVILLE PHYSICAL THERAPY AND SPORTS REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:JUDD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:817-498-3919
Mailing Address - Street 1:1109 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5849
Mailing Address - Country:US
Mailing Address - Phone:817-498-3919
Mailing Address - Fax:817-498-7080
Practice Address - Street 1:1109 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5489
Practice Address - Country:US
Practice Address - Phone:817-498-3919
Practice Address - Fax:817-498-7080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0097EXOtherBLUE CROSS BLUE SHIELD
TX0097EXOtherBLUE CROSS BLUE SHIELD