Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2032464 | TX |
NPI | 1013497460 |
---|---|
Provider Name | Susette Damron |
First Address | Southlake, TX 76092-0306 |
Second Address | Southlake, TX 76092-0306 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2018 |
Last Update Date | 15/08/2018 |