MEDICARE: KELSEY MACTOUGH PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2177868	TX

General Provider Information

NPI Number	:	1114607074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY MACTOUGH PTA

Provider Business Mailing Address
First Line	:	521 INTERSTATE 45 S STE 4
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-5649
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 INTERSTATE 45 S STE 4
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77340-5649
Country	:	US
Telephone Number	:	936-293-8800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	07/24/2023

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Directions to “ KELSEY MACTOUGH PTA” Practice Location

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