Provider Demographics
NPI:1194760371
Name:PESNELL, KEITH WADE (PT)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:WADE
Last Name:PESNELL
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 1:421 S VELASCO ST
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-6015
Mailing Address - Country:US
Mailing Address - Phone:979-848-1886
Mailing Address - Fax:979-848-1376
Practice Address - Street 1:2327 W HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-7455
Practice Address - Country:US
Practice Address - Phone:979-848-1886
Practice Address - Fax:979-848-1376
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1090983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T1026OtherBCBS PROVIDER #
TX160159301Medicaid
TX8T1026OtherBCBS PROVIDER #