Healthcare Provider Details

I. General information

NPI: 1275682239
Provider Name (Legal Business Name): KELLEY TRCKA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1847 W STATE HIGHWAY 46 STE D
NEW BRAUNFELS TX
78132-4740
US

IV. Provider business mailing address

19 GRUENE PARK DR
NEW BRAUNFELS TX
78130-2459
US

V. Phone/Fax

Practice location:
  • Phone: 830-606-1200
  • Fax:
Mailing address:
  • Phone: 830-606-1200
  • Fax: 830-606-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1136737
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: