Provider Demographics
NPI:1619709326
Name:WALL, PAYTON B (PT,DPT)
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:B
Last Name:WALL
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 SINGLE TREE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-1850
Mailing Address - Country:US
Mailing Address - Phone:254-485-1657
Mailing Address - Fax:
Practice Address - Street 1:609 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3836
Practice Address - Country:US
Practice Address - Phone:940-627-5921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1399049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist