Healthcare Provider Details

I. General information

NPI: 1730648601
Provider Name (Legal Business Name): CIRCLE OF LIFE THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 07/28/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2993 S WATSON RD 200
GRAND PRAIRIE TX
75052
US

IV. Provider business mailing address

2993 S STATE HIGHWAY 360 STE 200
GRAND PRAIRIE TX
75052-8906
US

V. Phone/Fax

Practice location:
  • Phone: 469-580-9733
  • Fax: 214-988-1542
Mailing address:
  • Phone: 469-580-9733
  • Fax: 214-988-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: LATARA HART
Title or Position: OWNER
Credential: MOT
Phone: 469-580-9733