Healthcare Provider Details

I. General information

NPI: 1063192904
Provider Name (Legal Business Name): GRACE BANIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 HARRIS PKWY
FORT WORTH TX
76132-6108
US

IV. Provider business mailing address

6601 HARRIS PKWY
FORT WORTH TX
76132-6108
US

V. Phone/Fax

Practice location:
  • Phone: 817-738-9866
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1376202
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: