Provider Demographics
NPI:1063514602
Name:DAVIDSON, WENDY MARY (LPT)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:MARY
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:MARY
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:PO BOX 2500
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087
Mailing Address - Country:US
Mailing Address - Phone:972-771-0999
Mailing Address - Fax:972-771-2281
Practice Address - Street 1:930 W RALPH HALL PARKWAY SUITE 120
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032
Practice Address - Country:US
Practice Address - Phone:972-771-0999
Practice Address - Fax:972-771-2281
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1097624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165348701Medicaid
TX165348701Medicaid