Provider Demographics
NPI:1992287619
Name:WALL, SHANE BRADLEY (PT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:BRADLEY
Last Name:WALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S HOUSTON ST.
Mailing Address - Street 2:
Mailing Address - City:DE LEON
Mailing Address - State:TX
Mailing Address - Zip Code:76444
Mailing Address - Country:US
Mailing Address - Phone:254-893-2015
Mailing Address - Fax:
Practice Address - Street 1:400 S HOUSTON ST
Practice Address - Street 2:
Practice Address - City:DE LEON
Practice Address - State:TX
Practice Address - Zip Code:76444-1928
Practice Address - Country:US
Practice Address - Phone:254-893-2015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1125359225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist