=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598448391
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPHYS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2023
-----------------------------------------------------
Last Update Date | 08/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7520 FM 3180 RD STE 400
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77523-5006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-720-0788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4311 CLEARWATER DR
-----------------------------------------------------
City | BAYTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77523-3524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-720-0788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAJA WILSON
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 601-720-0788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------