Provider Demographics
NPI:1952166241
Name:LIGHT, PHILLIP MICHAEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:LIGHT
Suffix:
Gender:M
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 1:12413 JUDSON RD STE 260
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3262
Mailing Address - Country:US
Mailing Address - Phone:210-337-7953
Mailing Address - Fax:210-337-7966
Practice Address - Street 1:3875 E SOUTHCROSS BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-3521
Practice Address - Country:US
Practice Address - Phone:210-337-7953
Practice Address - Fax:210-337-7966
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1389403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist