Provider Demographics
NPI:1083965610
Name:WALLIN, KELSEY B
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:B
Last Name:WALLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12709 TOEPPERWEIN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3259
Mailing Address - Country:US
Mailing Address - Phone:210-477-5151
Mailing Address - Fax:210-477-5152
Practice Address - Street 1:8715 VILLAGE DR STE 120
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5425
Practice Address - Country:US
Practice Address - Phone:210-477-5151
Practice Address - Fax:210-477-5152
Is Sole Proprietor?:No
Enumeration Date:2012-09-22
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
WAPT 60216897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1209640OtherPHYSICAL THERAPIST LISCENCE NUMBER