Healthcare Provider Details

I. General information

NPI: 1972645604
Provider Name (Legal Business Name): VIVIAN ELAINE CANNIZZARO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3234 OLD CHAPEL DR
SPRING TX
77373-6050
US

IV. Provider business mailing address

17198 ST LUKES WAY SUITE 600
THE WOODLANDS TX
77384-8011
US

V. Phone/Fax

Practice location:
  • Phone: 281-651-0837
  • Fax:
Mailing address:
  • Phone: 936-273-2215
  • Fax: 936-273-2130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2028884
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: