Healthcare Provider Details

I. General information

NPI: 1811565930
Provider Name (Legal Business Name): KELSIE MAE WALTHERS OTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 AMADOR DR
FORT WORTH TX
76177-2227
US

IV. Provider business mailing address

204 CREEKWOOD RANCH RD
AZLE TX
76020-8047
US

V. Phone/Fax

Practice location:
  • Phone: 682-204-0853
  • Fax:
Mailing address:
  • Phone: 719-355-6292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number216827
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: