Healthcare Provider Details

I. General information

NPI: 1205316312
Provider Name (Legal Business Name): ADAM FOSSETT MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 DOGWOOD DR
LITTLE RIVER ACADEMY TX
76554-2821
US

IV. Provider business mailing address

PO BOX 568
BELTON TX
76513-0568
US

V. Phone/Fax

Practice location:
  • Phone: 254-939-0808
  • Fax:
Mailing address:
  • Phone: 254-939-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1139582
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: