Provider Demographics
NPI:1215690227
Name:DERILUS, KESIA
Entity type:Individual
Prefix:
First Name:KESIA
Middle Name:
Last Name:DERILUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12660 HILLCREST RD APT 6201
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2028
Mailing Address - Country:US
Mailing Address - Phone:954-560-0951
Mailing Address - Fax:
Practice Address - Street 1:814 E CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-2828
Practice Address - Country:US
Practice Address - Phone:214-217-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-16
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2144804225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant