Provider Demographics
NPI:1124880240
Name:LEAD PEDIATRIC PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:LEAD PEDIATRIC PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISSY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOHER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PCS
Authorized Official - Phone:571-212-6145
Mailing Address - Street 1:4912 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-2435
Mailing Address - Country:US
Mailing Address - Phone:571-212-6145
Mailing Address - Fax:817-264-7958
Practice Address - Street 1:610 S JENNINGS AVE STE E
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3209
Practice Address - Country:US
Practice Address - Phone:682-231-2674
Practice Address - Fax:817-264-7958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty