Healthcare Provider Details

I. General information

NPI: 1114904760
Provider Name (Legal Business Name): KELLY M. HALL P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4501
US

IV. Provider business mailing address

3 NORTHWEST RD
UNIVERSAL CITY TX
78148-5629
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-1920
  • Fax:
Mailing address:
  • Phone: 210-945-9552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1167052401
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: