=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922309061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY J. QUAAL P.T., O.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2010
-----------------------------------------------------
Last Update Date | 11/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 879 EUREKA ST
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-5807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-594-9200
-----------------------------------------------------
Fax | 817-594-9202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2306
-----------------------------------------------------
City | WEATHERFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76086-7306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-594-9200
-----------------------------------------------------
Fax | 817-594-9202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1177880
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 112191
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------