=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083573620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRIDE PHYSICAL THERAPY AND PERFORMANCE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2026
-----------------------------------------------------
Last Update Date | 01/20/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2119 FRATE BARKER RD UNIT 2105
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78748-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-769-6162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8105 MARIGNY WAY
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78744-1179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-769-6162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. EDWARD SCOTT NICKLAS
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 336-769-6162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------