Provider Demographics
NPI:1902146152
Name:PEDIATRIC AND SPORTS PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:PEDIATRIC AND SPORTS PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:972-429-2187
Mailing Address - Street 1:211 REGENCY DR
Mailing Address - Street 2:STE 200
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-7011
Mailing Address - Country:US
Mailing Address - Phone:972-429-2187
Mailing Address - Fax:727-429-2252
Practice Address - Street 1:211 REGENCY DRIVE
Practice Address - Street 2:STE 200
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-7011
Practice Address - Country:US
Practice Address - Phone:972-429-2187
Practice Address - Fax:727-429-2252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1219370225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1219370OtherLICENSE