Healthcare Provider Details

I. General information

NPI: 1235352436
Provider Name (Legal Business Name): SOFIA WILTENS LPT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W BEN WHITE BLVD 211A
AUSTIN TX
78704-6888
US

IV. Provider business mailing address

1221 W BEN WHITE BLVD 211A
AUSTIN TX
78704-6888
US

V. Phone/Fax

Practice location:
  • Phone: 512-707-8392
  • Fax: 512-707-2841
Mailing address:
  • Phone: 512-707-8392
  • Fax: 512-707-2841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1062495
License Number StateTX

VIII. Authorized Official

Name: MRS. SOFIA S. WILTENS SR.
Title or Position: DIRECTOR/LPT
Credential: LPT
Phone: 512-707-8392