Healthcare Provider Details

I. General information

NPI: 1376735167
Provider Name (Legal Business Name): KELLY KATHLEEN GUMBERT PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80005 CORNERWOOD DR
AUSTIN TX
78717
US

IV. Provider business mailing address

11104 SPICEWOOD CLUB DR
AUSTIN TX
78750
US

V. Phone/Fax

Practice location:
  • Phone: 512-238-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1114866
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: