Healthcare Provider Details

I. General information

NPI: 1578042438
Provider Name (Legal Business Name): ANNETTE GAYLE TADLOCK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 08/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 GREENE ST
WEBSTER TX
77598-6701
US

IV. Provider business mailing address

7110 HOLLY BAY CT
PASADENA TX
77505-6400
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-4738
  • Fax:
Mailing address:
  • Phone: 713-705-2939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1050615
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: