Provider Demographics
NPI:1548651078
Name:CORREA, JUAN P (PTA)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:P
Last Name:CORREA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 BERKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-1219
Mailing Address - Country:US
Mailing Address - Phone:281-536-3051
Mailing Address - Fax:
Practice Address - Street 1:6213 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-7036
Practice Address - Country:US
Practice Address - Phone:713-880-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2056009225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant