MEDICARE: DAVINA ANDREA DEEN PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2129301	TX

General Provider Information

NPI Number	:	1235619172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVINA ANDREA DEEN PTA

Provider Business Mailing Address
First Line	:	3912 SAN LUIS CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-2741
Country	:	US
Telephone Number	:	816-217-1658
Fax Number	:

Provider Business Practice Location Address
First Line	:	4515 VILLAGE CREEK RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4158
Country	:	US
Telephone Number	:	817-451-8704
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2018
Last Update Date	:	08/20/2018

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