Provider Demographics
NPI:1811144686
Name:WALES, BRYAN (PT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9104 WILD ROSE LN
Mailing Address - Street 2:
Mailing Address - City:CROSSROADS
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2319
Mailing Address - Country:US
Mailing Address - Phone:972-533-0276
Mailing Address - Fax:
Practice Address - Street 1:26795 EAST HIGHWAY 380
Practice Address - Street 2:SUITE 200
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227
Practice Address - Country:US
Practice Address - Phone:972-347-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1183117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist