Provider Demographics
NPI:1306328802
Name:GEORGE, WANDA CRYSTAL (PTA)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:CRYSTAL
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 BLUE STEM
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-1733
Mailing Address - Country:US
Mailing Address - Phone:469-863-1952
Mailing Address - Fax:
Practice Address - Street 1:8300 ELDORADO PKWY
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-7507
Practice Address - Country:US
Practice Address - Phone:972-838-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225200000X
TX2014981225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant