Provider Demographics
NPI:1760229330
Name:SOMERVILLE, NOAH DWAYNE
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:DWAYNE
Last Name:SOMERVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9458 LAIDEN CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77303-2047
Mailing Address - Country:US
Mailing Address - Phone:903-390-1605
Mailing Address - Fax:
Practice Address - Street 1:20639 KUYKENDAHL RD STE 200
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3587
Practice Address - Country:US
Practice Address - Phone:832-698-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4063543225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant