Provider Demographics
NPI:1407974231
Name:MOOTZ, TINA (PT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MOOTZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 CLEAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-3660
Mailing Address - Country:US
Mailing Address - Phone:972-386-6310
Mailing Address - Fax:972-404-9150
Practice Address - Street 1:12890 HILLCREST RD
Practice Address - Street 2:SUITE 201
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1504
Practice Address - Country:US
Practice Address - Phone:972-386-6310
Practice Address - Fax:972-404-9150
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1062511174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist