Healthcare Provider Details

I. General information

NPI: 1669955480
Provider Name (Legal Business Name): KERRY L HUANG PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KERRY L BANCOCK

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S PARK DR STE D
BROWNWOOD TX
76801-5957
US

IV. Provider business mailing address

309 POCO ST
BANGS TX
76823-3462
US

V. Phone/Fax

Practice location:
  • Phone: 254-931-4826
  • Fax:
Mailing address:
  • Phone: 254-931-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2069548
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: