Provider Demographics
NPI:1366651861
Name:ROACH, KELLY M (PT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ROACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7208 SABLE LN
Mailing Address - Street 2:
Mailing Address - City:SACHSE
Mailing Address - State:TX
Mailing Address - Zip Code:75048-2522
Mailing Address - Country:US
Mailing Address - Phone:972-442-9503
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:214-467-9787
Practice Address - Fax:214-741-3655
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1156113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist