Provider Demographics
NPI:1588164016
Name:DORNBACK, MATTIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:DORNBACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 FARGO DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-2757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 W UNIVERSITY DR STE 119
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-3219
Practice Address - Country:US
Practice Address - Phone:972-569-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-11-15
Deactivation Date:2018-03-16
Deactivation Code:
Reactivation Date:2018-11-05
Provider Licenses
StateLicense IDTaxonomies
TX1300189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist