Provider Demographics
NPI:1992229181
Name:BROOKS, WALTER WAYNE (PTA)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:WAYNE
Last Name:BROOKS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:W
Other - Middle Name:WAYNE
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9625 LEA SHORE ST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3226
Mailing Address - Country:US
Mailing Address - Phone:817-236-5543
Mailing Address - Fax:817-236-5543
Practice Address - Street 1:9625 LEA SHORE ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3226
Practice Address - Country:US
Practice Address - Phone:817-236-5544
Practice Address - Fax:817-236-5543
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2017802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty