Basic Information
| Provider Information | |||||||||
| NPI: | 1962494104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANGFORD | ||||||||
| FirstName: | TANDRA | ||||||||
| MiddleName: | LOVE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRILLHART | ||||||||
| OtherFirstName: | TANDRA | ||||||||
| OtherMiddleName: | LOVE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5950 BRYANT IRVIN RD | ||||||||
| Address2: | #100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761324210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172944646 | ||||||||
| FaxNumber: | 8172944649 | ||||||||
| Practice Location | |||||||||
| Address1: | 5950 BRYANT IRVIN RD | ||||||||
| Address2: | #100 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761324210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172944646 | ||||||||
| FaxNumber: | 8172944649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 01/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1136232 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 062865301 | 05 | TX | MEDICAID | 8T0363 | 01 | TX | BCBS | OTHER |