Provider Demographics
NPI:1083803605
Name:DORTCH, KELLY L (DPT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:DORTCH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14703 EAGLE VISTA DR
Mailing Address - Street 2:BUILDING 601
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5394
Mailing Address - Country:US
Mailing Address - Phone:281-249-7103
Mailing Address - Fax:281-249-7194
Practice Address - Street 1:100 WIMBLEDON SQ
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4931
Practice Address - Country:US
Practice Address - Phone:757-547-5145
Practice Address - Fax:757-436-2480
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205166225100000X
TX1192880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1192880OtherSTATE LICENSE NUMBER
VA2305205166OtherVA LICENSE