Provider Demographics
NPI:1992244388
Name:WITHROW, DARRYL BLAKE (PT)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:BLAKE
Last Name:WITHROW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:
Other - Last Name:WITHROW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:931 YORK DR
Practice Address - Street 2:SUITE A
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2043
Practice Address - Country:US
Practice Address - Phone:972-296-6645
Practice Address - Fax:972-296-4526
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1287741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist