=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013451178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA BETTIN PT, LMT, CST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2016
-----------------------------------------------------
Last Update Date | 12/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12840 HILLCREST RD E104
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-404-3077
-----------------------------------------------------
Fax | 972-404-1124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12840 HILLCREST RD E104
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75230-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-404-3077
-----------------------------------------------------
Fax | 972-404-1124
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1111003
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------