MEDICARE: FONTENELLE PHYSIOTHERAPY, PLLC DBA CALIBER REHAB AND PERFORMANCE

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1972449403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FONTENELLE PHYSIOTHERAPY, PLLC DBA CALIBER REHAB AND PERFORMANCE

Provider Business Mailing Address
First Line	:	2104 N AUSTIN AVE # 105
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-4511
Country	:	US
Telephone Number	:	512-761-7307
Fax Number	:	737-787-2773

Provider Business Practice Location Address
First Line	:	2104 N AUSTIN AVE # 105
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-4511
Country	:	US
Telephone Number	:	512-761-7307
Fax Number	:	737-787-2773

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GLEN FONTENELLE
Credential	:	PT, DPT
Telephone Number	:	512-761-7307

Provider Enumeration Date	:	04/27/2026
Last Update Date	:	04/27/2026

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