Provider Demographics
NPI:1376765065
Name:BARE, KELLY S (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:BARE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BEAR RUN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-1267
Mailing Address - Country:US
Mailing Address - Phone:254-709-4566
Mailing Address - Fax:
Practice Address - Street 1:150 BEAR RUN
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1267
Practice Address - Country:US
Practice Address - Phone:254-709-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT34042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer