MEDICARE: MANDY WITHERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1328802	TX
2	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417590258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDY WITHERS

Provider Business Mailing Address
First Line	:	1201 S INTERSTATE 35 STE 105
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-6646
Country	:	US
Telephone Number	:	512-310-7665
Fax Number	:	512-310-9228

Provider Business Practice Location Address
First Line	:	1201 S IH 35 STE 105
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-6646
Country	:	US
Telephone Number	:	512-310-7665
Fax Number	:	512-310-9228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	09/18/2020

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Directions to “ MANDY WITHERS ” Practice Location

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