Provider Demographics
NPI:1417706821
Name:HOWARD, KEELY (PTA)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:
Last Name:HOWARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76458-2325
Mailing Address - Country:US
Mailing Address - Phone:610-290-2349
Mailing Address - Fax:
Practice Address - Street 1:5100 STONE LAKE DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-8017
Practice Address - Country:US
Practice Address - Phone:940-689-7200
Practice Address - Fax:940-689-7220
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2104370208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation