Healthcare Provider Details

I. General information

NPI: 1831816263
Provider Name (Legal Business Name): MACIE ROSE SOUTHARD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 OLD JACKSBORO HWY STE 101
WICHITA FALLS TX
76302-2700
US

IV. Provider business mailing address

4309 OLD JACKSBORO HWY STE 101
WICHITA FALLS TX
76302-2700
US

V. Phone/Fax

Practice location:
  • Phone: 940-386-1004
  • Fax: 940-386-9944
Mailing address:
  • Phone: 940-386-1004
  • Fax: 940-386-9944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2173083
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: