MEDICARE: WALTER WAYNE BROOKS 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	2017802	TX

General Provider Information

NPI Number	:	1992229181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALTER WAYNE BROOKS PTA

Provider Business Mailing Address
First Line	:	9625 LEA SHORE ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76179-3226
Country	:	US
Telephone Number	:	817-236-5543
Fax Number	:	817-236-5543

Provider Business Practice Location Address
First Line	:	9625 LEA SHORE ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76179-3226
Country	:	US
Telephone Number	:	817-236-5544
Fax Number	:	817-236-5543

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

Provider Enumeration Date	:	07/28/2017
Last Update Date	:	07/28/2017

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Directions to “ WALTER WAYNE BROOKS PTA” Practice Location

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