Provider Demographics
NPI:1346019734
Name:CHAVEZ, KIMBERLLY CHAWNTAE (PTA, CLT)
Entity type:Individual
Prefix:
First Name:KIMBERLLY
Middle Name:CHAWNTAE
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:PTA, CLT
Other - Prefix:
Other - First Name:KIMBERLLY
Other - Middle Name:CHAWNTAE
Other - Last Name:CEPEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA, CLT
Mailing Address - Street 1:3875 E SOUTHCROSS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-3521
Mailing Address - Country:US
Mailing Address - Phone:210-763-0775
Mailing Address - Fax:
Practice Address - Street 1:3875 E SOUTHCROSS BLVD STE A
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:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2148253225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant