Provider Demographics
NPI:1255964847
Name:WILMOTH, CLINTON REESE
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:REESE
Last Name:WILMOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4804 E SAM HOUSTON PKWY S STE 200
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3961
Mailing Address - Country:US
Mailing Address - Phone:281-487-4457
Mailing Address - Fax:
Practice Address - Street 1:4804 E SAM HOUSTON PKWY S STE 200
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3961
Practice Address - Country:US
Practice Address - Phone:281-487-4457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1306053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist