Provider Demographics
NPI:1457107773
Name:TYE, DAWN RENE
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:RENE
Last Name:TYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MILKY WAY RD
Mailing Address - Street 2:
Mailing Address - City:BRUCEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76630-3450
Mailing Address - Country:US
Mailing Address - Phone:254-485-4191
Mailing Address - Fax:
Practice Address - Street 1:131 MILKY WAY RD
Practice Address - Street 2:
Practice Address - City:BRUCEVILLE
Practice Address - State:TX
Practice Address - Zip Code:76630-3450
Practice Address - Country:US
Practice Address - Phone:912-544-8541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2021358225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant