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General NPI Number Information
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NPI Number | 1316554595
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Entity Type | Individual
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Provider Name | BRANT EDWARD COSTILLA PTA
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Gender | Male
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Dates
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Enumeration Date | 09/30/2020
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 2112 FORUM PKWY
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City | BEDFORD
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State | TX
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Zip | 76021-6028
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Country | US
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Telephone | 817-799-4909
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Fax |
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Provider Business Mailing Address
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Address Line | 1814 WOOD DUCK CT
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City | MIDLOTHIAN
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State | TX
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Zip | 76065-9427
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Country | US
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Telephone | 469-222-7619
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2131372
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License Number State | TX
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