MEDICARE: KELSIE MAE WALTHERS OTA/L

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	224Z00000X	Occupational Therapy Assistant	216827	TX

General Provider Information

NPI Number	:	1811565930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSIE MAE WALTHERS OTA/L

Provider Business Mailing Address
First Line	:	204 CREEKWOOD RANCH RD
Second Line	:
City	:	AZLE
State	:	TX
Zip	:	76020-8047
Country	:	US
Telephone Number	:	719-355-6292
Fax Number	:

Provider Business Practice Location Address
First Line	:	3401 AMADOR DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-2227
Country	:	US
Telephone Number	:	682-204-0853
Fax Number	:

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

Provider Enumeration Date	:	06/15/2021
Last Update Date	:	06/15/2021

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