Provider Demographics
NPI:1336441823
Name:QUIBEN, MYLA (PT)
Entity Type:Individual
Prefix:
First Name:MYLA
Middle Name:
Last Name:QUIBEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MYLES
Other - Middle Name:
Other - Last Name:QUIBEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, PHD, DPT, GCS
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11989532251G0304X, 2251N0400X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343396301Medicaid
TX8TAC71OtherBCBS
TX343396301Medicaid