MEDICARE: KELLY LYNNE SACKY 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	2007134	TX

General Provider Information

NPI Number	:	1831181585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LYNNE SACKY PTA

Provider Business Mailing Address
First Line	:	6300 WEST LOOP S
Second Line	:	SUITE 118
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2900
Country	:	US
Telephone Number	:	713-661-2900
Fax Number	:	713-661-2999

Provider Business Practice Location Address
First Line	:	6300 WEST LOOP S
Second Line	:	SUITE 118
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2900
Country	:	US
Telephone Number	:	713-661-2900
Fax Number	:	713-661-2999

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/08/2007

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