Provider Demographics
NPI:1457716524
Name:BABISAK, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BABISAK
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 1:2500 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3702
Mailing Address - Country:US
Mailing Address - Phone:972-824-7714
Mailing Address - Fax:972-882-7611
Practice Address - Street 1:2500 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3702
Practice Address - Country:US
Practice Address - Phone:972-824-7714
Practice Address - Fax:972-882-7611
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT41182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer