Healthcare Provider Details

I. General information

NPI: 1023785599
Provider Name (Legal Business Name): KELSEY D'NAE TZOBANAKIS OTR, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 08/24/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5612 EDWARDS RANCH RD
FORT WORTH TX
76109-4145
US

IV. Provider business mailing address

10120 WESTPARK DR
BENBROOK TX
76126-4045
US

V. Phone/Fax

Practice location:
  • Phone: 817-420-9238
  • Fax:
Mailing address:
  • Phone: 325-721-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number114009
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: