Basic Information
| Provider Information | |||||||||
| NPI: | 1104185669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARRISON | ||||||||
| FirstName: | DOROTHY | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2500 | ||||||||
| Address2: | |||||||||
| City: | ROCKWALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750879000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727710999 | ||||||||
| FaxNumber: | 9727712281 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S VIRGINIA ST | ||||||||
| Address2: | STE B | ||||||||
| City: | TERRELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751603717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725249100 | ||||||||
| FaxNumber: | 9725249101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2012 | ||||||||
| LastUpdateDate: | 05/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2068019 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 165348701 | 05 | TX | MEDICAID |