Provider Demographics
NPI:1275200529
Name:KENNERLY, VICTORIA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 ROBISON RD
Mailing Address - Street 2:
Mailing Address - City:COLDSPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77331-7229
Mailing Address - Country:US
Mailing Address - Phone:713-591-9557
Mailing Address - Fax:
Practice Address - Street 1:2956 I-45 NORTH
Practice Address - Street 2:SUITE 500
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77303
Practice Address - Country:US
Practice Address - Phone:936-441-4422
Practice Address - Fax:936-441-4427
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2096448225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant