Provider Demographics
NPI:1740054782
Name:MILLAN, PHILLIP (PTA)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MILLAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 HARWOOD RD APT 1224
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-0422
Mailing Address - Country:US
Mailing Address - Phone:409-622-1380
Mailing Address - Fax:
Practice Address - Street 1:3645 N BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3242
Practice Address - Country:US
Practice Address - Phone:817-759-0004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2157358225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant