Provider Demographics
NPI:1124382684
Name:KELLY, TIMOTHY DAVID
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 11TH PL
Mailing Address - Street 2:
Mailing Address - City:SHALLOWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79363-5139
Mailing Address - Country:US
Mailing Address - Phone:806-281-7550
Mailing Address - Fax:
Practice Address - Street 1:1404 11TH PL
Practice Address - Street 2:
Practice Address - City:SHALLOWATER
Practice Address - State:TX
Practice Address - Zip Code:79363-5139
Practice Address - Country:US
Practice Address - Phone:806-281-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1168068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX676535Medicare PIN
TX149984001Medicaid