Provider Demographics
NPI:1245455963
Name:NORTH EAST REHAB CENTER WILLOWBROOK
Entity type:Organization
Organization Name:NORTH EAST REHAB CENTER WILLOWBROOK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHIRAH
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:281-646-1935
Mailing Address - Street 1:13300 HARGRAVE RD
Mailing Address - Street 2:SUITE 490
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4373
Mailing Address - Country:US
Mailing Address - Phone:281-646-1935
Mailing Address - Fax:281-646-0927
Practice Address - Street 1:13300 HARGRAVE RD
Practice Address - Street 2:SUITE 490
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4373
Practice Address - Country:US
Practice Address - Phone:281-646-1935
Practice Address - Fax:281-646-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1081537225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1081537OtherPHYSICAL THERAPY LICENSE
TX650546OtherBCBS ID
TX=========OtherTAX ID
TX650546OtherBCBS ID