Provider Demographics
NPI:1194892810
Name:WALLACE, KELLY (PT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8619 BROADWAY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-8496
Mailing Address - Country:US
Mailing Address - Phone:281-485-4818
Mailing Address - Fax:281-485-5446
Practice Address - Street 1:8619 BROADWAY ST STE 200
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8496
Practice Address - Country:US
Practice Address - Phone:281-485-4818
Practice Address - Fax:281-485-5446
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1050854225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1050854OtherP.T. LICENSE
TX1050854OtherP.T. LICENSE