Provider Demographics
NPI:1134124985
Name:WALTERS, KEVIN LEE (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 FOREST RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-1066
Mailing Address - Country:US
Mailing Address - Phone:817-457-0077
Mailing Address - Fax:817-457-8017
Practice Address - Street 1:809 W HARWOOD RD
Practice Address - Street 2:STE 103
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3289
Practice Address - Country:US
Practice Address - Phone:817-283-5252
Practice Address - Fax:817-283-5283
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1053353225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic