Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 1-3699-4 | TX |
NPI | 1053774349 |
---|---|
Provider Name | Mrs. Jane Davis |
First Address | Montgomery, TX 77356-5966 |
Second Address | Montgomery, TX 77356-5966 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2016 |
Last Update Date | 04/04/2016 |