Healthcare Provider Details

I. General information

NPI: 1689269771
Provider Name (Legal Business Name): DELESHA QUALLS PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PENNSYLVANIA AVE
ROSWELL NM
88201-4754
US

IV. Provider business mailing address

36 HOLLY LOOP
ROSWELL NM
88201-8368
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-9101
  • Fax:
Mailing address:
  • Phone: 281-840-9741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5376
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1278361
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: