Healthcare Provider Details

I. General information

NPI: 1639461668
Provider Name (Legal Business Name): WENDI MASTROIANNI MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 8TH AVE
FORT WORTH TX
76104-4137
US

IV. Provider business mailing address

1307 8TH AVE
FORT WORTH TX
76104-4137
US

V. Phone/Fax

Practice location:
  • Phone: 817-529-7555
  • Fax:
Mailing address:
  • Phone: 817-529-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15302
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number008742
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number1229173
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: