Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1005205 | TX |
NPI | 1003163973 |
---|---|
Provider Name | Joan Mildred Riddle |
First Address | Dallas, TX 75243 |
Second Address | Dallas, TX 75243-0587 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2012 |
Last Update Date | 10/08/2012 |