=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124880240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAD PEDIATRIC PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2024
-----------------------------------------------------
Last Update Date | 01/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3462 BLUE BONNET CIR STE A
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-2962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-231-2674
-----------------------------------------------------
Fax | 817-264-7958
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4912 RIVERBEND DR
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-212-6145
-----------------------------------------------------
Fax | 817-264-7958
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISSY BOOHER
-----------------------------------------------------
Credential | PT, PCS
-----------------------------------------------------
Telephone | 571-212-6145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------