Provider Demographics
NPI:1831615798
Name:MCRAE, ROSS ELLIOTT (LAT)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:ELLIOTT
Last Name:MCRAE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:MR
Other - First Name:ROSS
Other - Middle Name:ELLIOTT
Other - Last Name:MCRAE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAT
Mailing Address - Street 1:4501 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76103-1160
Mailing Address - Country:US
Mailing Address - Phone:817-457-2920
Mailing Address - Fax:
Practice Address - Street 1:4501 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-1160
Practice Address - Country:US
Practice Address - Phone:817-800-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT33482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer