Basic Information
Provider Information | |||||||||
NPI: | 1992166581 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREATER LEWISVILLE THERAPY CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GREATER THERAPY CENTERS-FORT WORTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 966 N GARDEN RIDGE BLVD | ||||||||
Address2: | SUITE 530 | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750772827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9724206605 | ||||||||
FaxNumber: | 9724362770 | ||||||||
Practice Location | |||||||||
Address1: | 5950 BRYANT IRVIN RD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761324210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8172944646 | ||||||||
FaxNumber: | 8443641297 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2016 | ||||||||
LastUpdateDate: | 08/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AITKEN | ||||||||
AuthorizedOfficialFirstName: | DENA | ||||||||
AuthorizedOfficialMiddleName: | KAY | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER-GTC | ||||||||
AuthorizedOfficialTelephone: | 9724206605 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: | 08/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 619640014 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.